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VED <br />y l i' -, 9 2011 SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />N V I R G N M E NTA LHEA1,'T 600 East Main Street, Stockton, CA 95202-3029 <br />r'1�FIMITISERUICI+>`1: ephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sigov.org/ehd <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 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 (IR) or Continuation Form, or <br />disputes to any violatioms, 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 a associated with failing to comply by the above noted dates will be billed at <br />the current hourly rate ($122). <br />For this certification t0 be complete the operator of the site must include: <br />• A statement docenting what corrective actions were taken or will be taken for each violation <br />• Copies of sampl results/manifests/training records/other appropriate paperwork, and/or photos <br />verifying corrections <br />• Operator's certification <br />Inspection Date: <br />Inspected By: Stacy Rivera <br />Facility Address: %3/ Z_ A1,11jci1 f-1 EPA 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 />WPhotos O1 Paperwork *" Statement <br />3. I am authorized D submit this certification on behalf of the Respondent. <br />4. 1 am aware that i here are significant penalties for submitting false information, including the <br />possibility of a f ne and/or imprisonment for known violations. (HSC 25191) <br />Name: Am41,p &//)e' A7fV4F Title: QtitlffV- <br />Si <br />EHD 22-02-005 Rev 08/1 <br />Date: %Izellj <br />