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Sep 26'11 02:40p D.T.S. 2Pn5326175 p.5 <br /> SAN JOAQUIN CouNTv <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 600 E.Main St,,Stockton,CA 95202-3029 <br /> Te phone.(209)468-3420 Far.(209)468-3433 Web.www.sj o�v_org/ehd <br /> RET TO COMPLIANCE CERTIFICATION <br /> Any MINOR violations oted in the"Notice to Comply"in the attached Inspection Report must be <br /> corrected within 30 days f 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 v olations noted in the attached Inspection Report or Continuation Form, or <br /> j disputes to any violations are to be submitted using this certification and returned to EHD within 30 days <br /> j unless otherwise specifie in the Inspection Report. <br /> j Note: All EHD staff ti associated with failing to comply by the above noted dates will be billed at <br /> the current hourly rate $12$). <br /> I <br /> I <br /> For this Certification to be complete the operator of the site must include: <br /> • A statement docu enting what corrective actions were taken or will betaken for each violation <br /> • Copies of sample esults/manifests/training records/other appropriate paperwork,and/or photos <br /> verifying correcti ns <br /> • Operator's certifi ation <br /> Inspection Date: Inspected By: <br /> Facility Address: 5� 1 �� Jf � EPA ID#: <br /> - <br /> I certify under penalty of law that: <br /> I <br /> 1. 1 have corrected th violations specified in the Inspection Report from the above-mentioned <br /> inspection date. <br /> 2. 1 have personally a amined the following documentation submitted as proof of compliance FOR <br /> EACH VIOLATI N and I believe the information to be true,accurate, and complete: <br /> t-,"', Photos ✓ Paperwork Statement <br /> 3. lam authorized tosubmit this certification on behalf of the Respondent. <br /> 4. I am aware that the are significant penalties for submitting false information,including the <br /> possibility of a fine and/or imprisonment for known violations. (HSC 25191) <br /> Name• ���� <f•;l '�• ��6�J��"'�' Title: �f <br /> Signature: ! Date: v JJ <br /> EHD 22-02-005 Rev 08/10 <br />