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FROM FAX N0. Wn. 14 2011 04:08PM P1 <br /> JUN 2011 <br /> { <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 600 Cast Main Street,Stockton,Cit 95202-3029 <br /> Telephone:(209)468-3420.fax:(209)468-3433 Web.www.si o� v.om/ehd <br /> RETURN TO COMPLIANCE CER.TIFfCATION <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 violations,are to be submitted using this certification and returned to EH.D within 30 dans <br /> unless otherwise specified in the Inspection Report. <br /> Note: All EI•iD staff time associated with failing to comply by the above noted dates will be billed at <br /> the current hourly rate($122). <br /> For this certification t® be C0lnplete 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 appropriate paperwork,and/or photos <br /> verifying corrections <br /> • Operator's certification <br /> Inspection Date: (nspected JBy: 7-h v y T'ra h. <br /> Facility Address: 5'/5- w 07" s r" -rrg5�t EPA ID#: CAI-0®od-g43/76 <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 /> Photos Paperwork K Statement <br /> 3. 1 am authorized to submit this certification on behalf,of the Respondent. <br /> 4. I 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 /> • � .- �'� !�e,n writ— Title: AsW. /n,aefaff-.efL <br /> Signature: Date: o `��'A000 <br /> EHD 22-02-005 Rev 08/10 <br />