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FROM FAX NO. 14 2012 04:13PM P1 <br /> L <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTW2NT <br /> 6401?.Wo St,Stockton,CA 95202-3029 JUN 1 4 2012 <br /> -(209)468-3420 F=(209)468-3433 Web.,www.0Sgv.gMt <br /> TdVhone. thd <br /> 6 <br /> RETURN TO COMIPLL4NCE CERTIFICATION <br /> Any OR violations noted in the"Notice to Comply"in the attached Inspection Report must be <br /> carr ocW,within 29-4=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 /> Jnspection Report. <br /> All 2=cfi=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 39 dW <br /> unless otherwise specified in the Inspection Report. <br /> Note: All ERD staff time associated with falling to comply by the above noted dates will be billed at <br /> the c hourly rate($12P. <br /> For this certification to be complete the 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 appropnate paperwork,and/or photos <br /> verifying corrections <br /> • Operator's certification <br /> Inspection Date: 5Ln:K :1 oLO1 r Inspected By:T h y� -F -LLL <br /> Facility Address: S-I :" Sr -rrq�qyo,EPA ID#: C It 4 oco � 7 V 116 <br /> I cerffy 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 V101ATION and I believe the information to be true,accurate,and complete: <br /> Photos X, Paperwork 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 2519 1) <br /> N <br /> ame: e ki Cox Titl e: 4 SS I's ta,or 0 ap q- V—r-- <br /> Signature: Date: 6L61112— <br /> EHD 22-02-4005 Rev 08/10 <br />