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SAN JOAQUIN COUNTY <br /> RECEIVED <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 600 E.Main St., Stockton,CA 95202-3029 y Z �� <br /> Tellephone:(209)468-3420 Fax.(209)468-3433 Web:www. ' �V.or ehd <br /> ENVIRONMENTAL HEALTH <br /> PERM 11ltit vRar-Q <br /> RETURN TO COMPLIANCE CERTIFICATION <br /> Any MINOR violations toted 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 D partment (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 or Continuation Form, or <br /> disputes to any violation , are to be submitted using this certification and returned to EHD within 30 days <br /> unless otherwise specifi in the Inspection Report. <br /> Note: All EHD staff time associated with failing to comply by the above noted dates will be billed at <br /> the current hourly rate i($105). <br /> For this certification t0 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 /> • Operator's certifi ation <br /> Inspection Date: /-�— � VV I sected yB , - h v <br /> Facility Address: ` O EPA ID#: � "�� <br /> I certify under penal of law that: <br /> 1. I have corrected t e violations specified in the Inspection Report from the above-mentioned <br /> inspection date. <br /> 2. I have personally xamined the following documentation submitted as proof of compliance FOR <br /> EACH VIOLATI N and believe the information to be true, accurate, and complete: <br /> i/dIPhotos Paperwork Statement <br /> 3. lam 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 fin and/or imprisonment for known violations. (HSC 25191) <br /> Name: �// ��' �<.{�� �ri W)P, Title: <br /> Signature: Y�� r_h ,�9 Jl Date: <br /> EHD 22-02-005 Rev 10-07 <br />