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SAN.JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT MAR 1 7 2010 <br /> 600 East Main Street, Stockton, CA 95202-3029 <br /> Telephone: (209)468-3420 Fax:(209)468-3433 Web:ww A ov.orPERMI ENT LT <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 dans of receipt of this inspection. This <br /> certification <br /> form with n 30 days of resubmitted <br /> ceipt of the <br /> the <br /> Environmental Health Department (EHD) address at the top ofthis <br /> Inspection Report. <br /> All corrections to other violations noted in the attached Inspection ficaand Report (IR) or returned within inuation m dans <br /> disputes to any violations, are to be submitted using this cert <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 <br /> billed at the current hourly rate. <br /> Tete the <br /> For this certification to be comp operator of the site must include: <br /> • A statement documenting what corrective actions were taken or will be taken for each violation <br /> • Copies of sample results/manifests/training records/other appropriate paperwork, and/or photos <br /> verifying corrections <br /> • Operator's certification <br /> ".. e ® a V <br /> Inspection Date:C <br /> Inspected By. �1JI -d�' <br /> `EPA ID : <br /> Facility Address: t', <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 <br /> sproof of a d complete:compliance FOR <br /> EACH VIOLATION and I believe the information to be true, accurate, <br /> Photos Paperwork Statement <br /> 3. I 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 /> • Title: St. <br /> Name: +-- ----- <br /> Signatur <br /> Date: <br />