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MAR-26-2010 16:47 SBC 9259730584 P.04 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 504 East Main Street, Stockton, CA 95202-3029 <br /> Teleph e: (209)468-3420 Fax:(209)468-3433 Web;www.sloov.org/ehd <br /> RETURN TO COMPLIANCE CERTIFICATION <br /> AnyIM NOR violations noted,in the "Notice to Comply" in the attached Inspection Report must be <br /> erected 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 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 /> Is utas to an viola ions are to be submitted using this certification and returned to EHD within 30 ays <br /> unless of erwise specified In the Inspection Report. <br /> Note: All EHD staff tiro gaoR dated with failing to comply by the above noted dates will be <br /> billed at the curr haimly rate. <br /> For this certificat on'tb 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 certification <br /> Inspection Date: (O Inspected By: .GA� wt-we'- <br /> Facility Address: 2,300 e- P__WMI!L p EPA ID#: CAT,06ogvo �.p <br /> I certify under penalty of law that: <br /> 1. I 14040R., SOFF e6the violations specified in the Inspection Report from the above-mentioned <br /> inspection date. <br /> 2. 1 have personally exafnned the following documentation submitted as proof of compliance FOR <br /> EACH VIOLATION an'471 believe the information to be true, accurate, and complete: <br /> Photos, V Paperwork V1 Statement <br /> 3. 1 am authorized to s mit,this certification on behalf of the Respondent. <br /> 4_ 1 am aware that then are significant penalties for submitting false information, including the <br /> possibility of a fine.a d/a imprisonment for known violations. (HSC 25191) <br /> Name: Title: tWlRpt��$.1'T� <br /> I <br /> j Signature: _._.. bate: <br /> EHO 22.02005 Rev 10/09 <br />