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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT iUII R 600 E.Main Sty,Stockton,CA 95202-3029 e%phone:(209)468-3420 Far(209)468-3433 Web: v or h PERMS ;<: RE URN TO COMPLIANCE CERTIFICATION Any MINOR violation noted in the"Notice to Comply"in the attached Inspection Report must be corrected within 30 da sof receipt of this inspection. This certification form must be submitted to the Environmental Health epartment(EHD)address at the top of this form within 35 days of receipt of the Inspection Report. All corrections to other iolations noted in the attached Inspection Report or Continuation Form, or disputes to any violations, are to be submitted using this certification and returned to EHD within 30 days unless otherwise specified in the Inspection Report. Note: All EHD staff time associated with failing to comply by the above noted dates will be billed at the current hogrly rate,($122). For this ce1'tlficatl ion t0 be complete the operator of the site must include: • A state ent documenting what corrective actions were taken or will be taken for each violation • Copies sample results/manifests/training records/other appropriate paperwork, and/or photos verifyin corrections • Operator s certification Inspection Date: Inspected t3y Facility Address: ' EPA ID#: 4 Poi V06�3 590.r I certify under penalty)of law that: 1. 1 have corrected the violations specified in the Inspection Report from the above-mentioned inspection date. 2. 1 have personally ekamined the following documentation submitted as proof of compliance FOR EACH VIOLATION and I believe the information to be true, accurate,and complete: Photos Paperwork Statement 3. I am authorized to submit this certification on behalf of the Respondent. 4. 1 am aware that the are significant penalties for submitting false information, includingthe possibility of a fine nd/or imprisonment for known violations. (HSC 25191) 13o6 6ve5fI Name: Title: Signature: Date: EHD 22-02-005 Rev p8/10