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002454 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 600 East Main Street, Stockton, CA 95202-3029 <br /> Telep:, ne:(209) 468-3420 Fax:(209)468-3433 Web:www.sjgov.orq/ehd <br /> RETYRN 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 0 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 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, re to be submitted using this certification and returned to EHD within 30 days <br /> unless otherwise specified in the Inspection Report. <br /> (dote: All EHD staff tim associated with failing to comply by the above noted dates will be <br /> billed at the curr nt hourly rate. <br /> For this CertlfiCa 1011 t0 be completethe operator of the site must include: <br /> • A statement docume ing what corrective actions were taken or will be taken for each violation <br /> • Copies of sample res Its/manifests/training records/other appropriate paperwork, and/or photos <br /> verifying corrections <br /> • Operator's certificatio <br /> Inspection Date: Inspected By: aIt <br /> Facility Address: ' It lQ - Df � EPA ID#: L4 j 061 LLQZ W6, <br /> CA qS2tb <br /> I certify under penalty f law that: <br /> 1. 1 have corrected th violations specified in the Inspection Report from the above-mentioned <br /> inspection date. <br /> 2. 1 have personally eiamined the following documentation submitted as proof of compliance FOR <br /> EACH VIOLATION land I believe the-information to be true, accurate, and complete: <br /> Photos_Paperwork Statement <br /> 3. I am authorized to submit this certification on behalf of the Respondent. <br /> I <br /> 4 1 am aware that there are significant penalties for submitting false information, including the <br /> possibility of a fine end/or imprisonment for known violations. (HSC 25191) <br /> N �AL k f' I L iFTitle: <br /> Signature ;� 5 ,' Date-._2 <br /> ��.. V✓C- �✓� l� d'HGt L� Ohl n `✓� � � ���4�14ti. �Yv �IL� i�� �jy Y,/ . <br /> +} (y Lv � v APL4TC pYsI,�,, ( p�i4l'b,V1 We, I,i�(I Syr�� �� 4 (��p� o� �� 1�4�Zci4 <br /> / <br /> L{/( lI/1 l -,cC,h G tr�/ Iy� r1's�tvs• l QVtlJCv�" �' ✓t �('fn ny �' "/L '7�.� i 7t <br /> EHD 22-02-005 Rev 08/08 J <br />