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VAN GE PGL Fax:2094661910 Aug 2 2013 16:49 P.02 <br />SAN JOAQUIN COUNTY l i.�. fir' � �w D <br />ENVIRONMENttAL HEALTH DEPARTMENT <br />600 E, Main St, Stockton, CA 952023029 <br />2'etephone; (209) 468.3420 Fax. (209) 468-3433 Web. _ r i 2013 <br />EMVI,17,10�,�11 L <br />RETURN TO COMPLIANCE CERTIFICATION <br />Any MINOR violations noted in the "Notice to Comply" in the attached Inspection Report must be <br />corrected within_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 o to other violatims 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 EHD Within 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 CoY plate 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 sigi <br />nficant penalties for submitting false information, including the <br />possibility of a fine and/or imprisonment for known violations. (HSC 25191) <br />Name: <br />"Y -M III M fine ue.,n4/iA <br />Title: <br />Date: <br />