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08/0812011 08:18 2099424346 MID_CAL TRACTOR PAGE 01/01 <br />�t <br />46 ,. <br />SAN JOAQUIN COUNTY i <br />ENWKONMENCAL HEAj_TH[ DEPARTMENT A�6 p <br />600 E. Main St., Stockton, CA 95202-3029 S 8 201j <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 Weh: M w!M,g "g org/didh �V , l!/CCU <br />RETURN TO COMPLIANCE CERTIFICATION <br />Any MOR violations noted in the "Notice to Comply" in the attached Inspection Report must'be <br />cLmm cd within.30 flays of receipt of this inspection. This certification forni must be submitted to the <br />Environmental Health Department (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 violations, are to be submitted using this certification and returned to E,ttD within 30 days <br />unless otherwise specified in the inspection Report. <br />Note: All E,IID staff' time associated with failing to comply by the above noted dates will be billed at <br />the current hourly rate (S122). <br />For this certification to be Complete the operator of the site must include: <br />e 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: j/ t W 120 E l Inspected By: I k uy I �-A 4 <br />Facility Address: L ! 2CJ - _ L-3 C.4,AO—T L?p4 Epp iD#:_ _ C A L_o o 0-3S8 t 3— <br />I certify under penalty of law that: <br />1. I have corrected the violations speeted in the Inspection Report from the above-mentioned <br />inspection date. <br />2. 1 have personally examined the following documentation submitted as proof of compliance ,FOR <br />EACH VIOLATION and I believe the information to be true, accurate, and complete: <br />Photos X Paperwork Statement <br />3. I am authorized to submit this certification on behalf of the Respondent. <br />4. I am aware that theft are significant penalties for submitting false information, including the <br />possibility of a fine and/or imprisonment for known violations. (HSC 25191) <br />Name: Q W G/t Title: <br />. .. .. Date: � � <br />