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'Sep. 9. 2010 4: 30PM EMBASSY SUITES No. 5882 P. 1 <br /> SAN JOAQUIN COUNTY <br /> ENWRoNmENTAL HEALTH DEPARTMENT <br /> 600 E.Main St., Stockton,CA 95202-3029 <br /> Telephone.-(209)468-3420 Fox;(209)468-3433 Web. www.sjgov.orgjehd <br /> AZI <br /> t9,t�tj <201 <br /> 0 <br /> RETURN TO COMPLIANCE CERTIFICATION /0 0 <br /> U/V. <br /> Any MINOR violations noted in the'Notice to Comply" in the' attached Inspection Report must be iF <br /> corrected within 30 days 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 corrections to other violations noted in the attached Inspection Report or Continuation Form, or <br /> disputes to any violations, are to be submitted using this certification and returned to EHD within 30 dM <br /> unless otherwise specified in the Inspection Report. <br /> Note: All EYID staff time associated with failing to comply by the above noted dates will be Wed at <br /> the current hourly rate ($105). <br /> For this certification to be complete the operator of the site must include: <br /> 0 A statement documenting what corrective actions were taken or will be taken for each violation <br /> 9 Copies of sample results/manifests/training records/other appropriate paperwork, and/or photos <br /> verifying corrections <br /> * Operator's certification <br /> Inspection Date: r) 16) Inspected By: +NC,V _K_ i u ere. k <br /> I <br /> Facility Address: 9,5)_o W.MRov\ ?,A— EPA ID#: CAL 0000 bR(D <br /> I certify under penalty of law that: <br /> 1. 1 have corrected the violations specified in the Inspection Report from the above-mentioned <br /> inspection date. <br /> 2. 1 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_Paperwork K Statement <br /> 3. 1 am authorized to submit this certification on behalf of the Respondent, <br /> 4. 1 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: C� . M, <br /> Signature: Date: <br /> EHD 22-02-005 Rev 10-07 <br />