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VAN GE PGL Fax:2094661910 Aug 2 2013 16:49 P. 02 <br /> SAN JOAQUIN COUNTY l�.fir' i�v�� �,��✓ <br /> ENVIRONMENt'AL HEALTH ISEPARTMENT <br /> 600 E,Main St,Stockton,CA 952023029 <br /> Telephone.(209)468.3420 Fax:(209)468-3433 Web:mmoKQjgqy.2tW U r 0 2 2 013 <br /> EN1,111ON1111`=NT L <br /> ? -,L;3-i U . 'rS I i4 ,4 <br /> RETURN TO COMPLIANCE CERTIFICATION <br /> Any MINOR violations noted in the°'Notice to Comply,in the attached Inspection Report must be <br /> corrected and_.' _30 d$vs of receipt of this inspection. This certification form must be submitted to the <br /> Environmental Health Department(EHD)address at the top of this form within 35 days of receipt of the <br /> Inspection Report. <br /> All gauqqtjo=to other violations noted in the attached Inspection Deport or Continuation Form,or <br /> disputes to any violations,are to be submitted using this certification and returned to EHDi hin 30 days <br /> unless otherwise specified in the Inspection Report. <br /> Note: All EHD staff time associated with failing to comply by the above noted dates will be billed at <br /> the current hourly rate($122). <br /> For this certification to be complete the operator of the site must include: <br /> a A statement documenting what corrective actions were taken or will be taken for each violation <br /> a Copies of sample results/manifests/training records/other appropriate paperwork, and/or photos <br /> verifying corrections <br /> a Operator's certification <br /> Inspection Tate: Inspected By: <br /> Facility Address:{��kt� e c A _'SPA ID#: <br /> I certify under penalty of law that: <br /> 1, I have corrected the violations specified in the Inspection Report from the above-mentioned <br /> inspection date. <br /> 2. I have personally examined the following documentation submitted as proof of compliance FOR <br /> EACH VIOLATION and I believe the information to be true, accurate, and complete: <br /> Photos 10, Paperwork Statement <br /> 3. I am authorized to submit this certification on behalf of the Respondent. <br /> 4, I am aware that there are significant penalties for submitting false information,including the <br /> possibility of a fine and/or imprisonment for known violations. (HSC 25191) <br /> Name: Title: �t <br /> v-. <br /> Sip!ture: Date: <br /> rsrxn nn m a,na u^—nw fl <br />