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RFOM 01 FAX NO. 19 2013 04:28PM P1 <br /> EVED <br /> $AN JOAOUIN COUNTY JUN 19 2013 <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 600 East Main Street, Stockton,CA 95202-3029 ENVIRONMENTAL <br /> Telephone.,(209)468-3420 Fax:(209)468-3433 Web:EM-9190—Y-0-6&W�DEPARTMENT <br /> RETURN TO COMPLIANCE CERTIFICATION <br /> Any MINOR violations noted in the"Notice to Comply" in the attached Inspection Report must be <br /> corregled within 30 da s of receipt of this inspection. This cert cation form must be submitted to the <br /> Environmental Health Department(EHD)address at the top of this form within 30 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 EHD md1hip N Oaya <br /> unless otherwise specified in the Inspection Report. <br /> Note: All EHD staff time associated with failing to comply lby'the above noted dates will be <br /> billed at the current hourly rate. <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 appropriate paperwork, and/or photos <br /> verifying corrections <br /> • Operators certification <br /> Inspection Date: Tu o-e-, G 3 Inspected <br /> I h <br /> Facility Address, 0 /5� 11'-r5f -Tpg4q EPA ID#: COO IQ �1-7 <br /> I certify under penalty of law that: <br /> I- I 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 VIOLATION and I believe the information to be true, accurate, and complete: <br /> Photos N/ Paperwork Statement <br /> 3. lam 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 /> Name: a ki Co 0 Title:. /�655-rc*t &Iq.hq.A4r <br /> Signature: Date__. _T_Q�Ke_ <br /> EHD 22-02-006 Rev icim <br />