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SAN JOAQUIN COUNTY <br /> r-NVIRONMENTAL HEALTH DEPARTMENT <br /> 600 East Main Street,Stockton,CA 95202-3029 <br /> Telep one:(209)468-3420 Fax:(209)468-3433 Web:www.sipov.org <br /> RETU TO COMPLIANCE CERTIFICATION <br /> Any MINOR violations not d 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 Dep ment(EHD) address at the top of this form within 35 days of receipt of the <br /> Inspection Report. <br /> All corrections to other viol tions noted in the attached Inspection Report (IR) or Continuation Form, or <br /> disputes to any violations, ate to be submitted using this certification and returned to EHD within 30 days <br /> unless otherwise specified i the Inspection Report. <br /> Note: All EHD staff time ssociated with failing to comply by the above noted dates will be billed at <br /> the current hourly rate. <br /> For this certifieati n to be Complete the operator of the site must include: <br /> • A statement docum ting what corrective actions were taken or will be taken for each violation <br /> • Copies of sample re ults/manifests/training records/other appropriate paperwork, and/or photos <br /> verifying correction <br /> • Operator's certificat on <br /> r.• <br /> Inspection Date: IV - G Inspected By: _Z15�� <br /> Facility Address: 54110, �/ '—� �* EPA ID#: 64-At CCfj_, 2 2VP-/ <br /> 7e y C' L <br /> I certify under penalty o law that: <br /> 1. I have corrected the iolations specified in the Inspection Report from the above-mentioned <br /> inspection date. <br /> 2. I have personally ex ined the following documentation submitted as proof of compliance FOR <br /> EACH VIOLATION and I believe the information to be true, accurate, and complete: <br /> Y' Photos t� Paperwork r-' Statement <br /> 3. I am authorized to su mit 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 fine a d/or imprisonment for known violations. (HSC 25191) <br /> Name: J_)/k'AJ f_- Title: 6Y01CI--t-� <br /> Signature: 2✓-A ��` � Date: / - 3 <br /> EHD 22-02-005 Rev 11/07 <br />