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SAN JOAQUIN COUNTY <br /> Dic-C 1 0 2008 ENVIRONMENTAL HEALTH DEPARTMENT <br /> 600 East Main Street,Stockton,CA 95202-3029 <br /> fW1P0tAAV-J1 HEALTH Tel hone:(209)468-3420 Fax:(209)468-3433 Web:www.si�ov.or ehd <br /> RET RN TO COMPLIANCE CERTIFICATION <br /> Any MINOR violations n ted in the"Notice to Comply" in the attached Inspection Report must be <br /> corrected within 30 days f receipt of this inspection. This certification form must be submitted to the <br /> Environmental Health De artment (EHI)) address at the top of this form within 35 days of receipt of the <br /> Inspection Report. <br /> All corrections to other vi lations noted in the attached Inspection Report(IR) 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 tim associated with failing to comply by the above noted dates will be billed at <br /> the current hourly rate. <br /> For this certificatlion t0 be complete the operator of the site must include: <br /> • A statement docuenting what corrective actions were taken or will be taken for each violation <br /> • Copies of sampleit <br /> sults/manifests/training records/other appropriate paperwork, and/or photos <br /> verifying correctis <br /> • Operator's certifiion <br /> i <br /> Inspection Date: Z Inspected By:(r,Pr-r-u-77 6'-qCA-Vvj <br /> C-1. U(3 S tfn.v16& <br /> Facility Address: CEPA. ID#: 6A0'? 8,k 3S ? 7 l -7 <br /> I certify under penalty f law that: <br /> 1. 1 have corrected th violations specified in the Inspection Report frotn the above-mentioned <br /> inspection date, <br /> 2. I have personally e amined the following documentation submitted as proof of compliance FOR <br /> EACH VIOLATIO and I believe the information to be true, accurate, and complete: <br /> Photos Paperwork Stat,.ment <br /> 3. I am authorized to s ibmit this certification on behalf of the Respondent. <br /> 4. 1 am aware that ther are significant penalties for submitting false information, including the <br /> possibility of a fine nd/or imprisonment for known violations. (HSC 2519 1) <br /> Name: S`T�P 1/ 19tFC`V Title: 6L)-J1 2 AUL <br /> Signature: Date: 12- �7 <br /> EHD 22-02-005 Rev/11/4 <br />