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' <br /> RECEIVED <br /> SAN JOAQU|NCOUNTY 17 20+4 <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1O88East Hazelton Axenue. Stockton, California Q52O5'6232 ENVIRONMENTAL <br /> Telephone: (209)4G8'3420 Fax. (209)468-3433 Web: u�»��«�� x~ <br /> HEALTH DEPARTMENT <br /> RETURN TO COMPLIANCE �~���U�U���U���� <br /> � �� � _ ��� CERTIFICATION <br /> Any MINOR violations noted in the "Notice to Comply" in the attached Inspection Report muot be <br /> corrected withi,n 30 daVs of receipt of this inspection. This certification form must be uubmi1had to the <br /> Environmen�al Health Department (EHD) address at the top of this form within 30 days of re(3E!ipt of the <br /> Inspection Report. HSC 25404.1.2(c)(1) <br /> AJ| s to other violations nobsdinU1ea�ached |nupecionReon� UR) orContnuaUonForm or <br /> disputes baanyvio|ahnns. are to be submitted using this certification 'and (IR) <br /> to EHO within 30 <br /> ' <br /> days <br /> unless otherwise specified inthe Inspection Report. HSC 25185(c)(3) <br /> Note: All E.HD staff time associated with failing to comply by the above noted dates will be <br /> billed atthe current hourly rate. <br /> For this certification to be c[lmD|efe thnopem&n/ ofthu site must include: <br /> ° 8 statement douumenUng what corrective actions were taken or will be taken for each vioiahon <br /> ^ Copies of sample results/manifests/training records/other appropriate paperwork, and/or photos <br /> verifying corrections <br /> ° Operator's certification <br /> ` <br /> Inspection Date- Inspected By: <br /> Ari <br /> Facility Address:- EPA ID#: OA-LL.0-3514 e 2-(,o <br /> I certify Linder penalty of law that: <br /> 1. 1 have corrected the violations specified in the Inspection Report frcm the above-mentioned <br /> inspection date. <br /> 2 1 have personally examined the following documentation submitted as proof of cornpliaice FOR <br /> EACH VIOLATION and | believe the information to be true, d complete: <br /> Phohzo I Papenaork `~' Statement <br /> � 3. | amauthorized (osubmit this certification onbehalf oftile Respondent. <br /> 4, / amuvvarothaithenyureaignifiuontpena|homhoryubmitdngha|uoinformadon including the <br /> Title:Possi of a fine and/or im it for known violations. (HSC 25191 <br /> Narne: LA,19 (V'%6-W- 7 J�k� — � <br /> �/� <br /> �----~---- Da <br /> -`��—'�= --� ------- --- -�-------�--------'---- ___- _J <br /> e��02-005Rev u411 9/1z <br />