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SAN JOAQUIN COUNTY RECEIVED <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />600 E. Main St., Stockton, CA 95202-3029 JUN 0 6 201' <br />Telephone: (209) 468-3420 Fax. (209) 468-3433 Web: www.sjgov.org/ehd <br />EW89NMEb11AUiFALTH <br />PERMIT/SERVICES <br />RETURN TO COMPLIANCE CERTIFICATION <br />Any MINOR violations noted 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 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 EHD within 30 days <br />unless otherwise specified in the Inspection Report. <br />Note: All EHD staff time associated with,failing to comply by the above noted dates will be billed at <br />the current hourly rate ($122). <br />For this certification t0 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: J l t I f 11 Inspected By: n UO ; ,Og <br />Facility Address: ®I D' /a eV P6, k�,�`, L,,- EPA ID#: (2)q f z1`3 2 <br />0-a.. � 5 33f� <br />I certify under penalty of law that: <br />I have corrected the violations specified in the Inspection Report from the above-mentioned <br />inspection date. <br />2. I 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 Paperwork K Statement <br />3. I am authorized to submit 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 and/or imprisonment for known violations. (HSC 25191) <br />Name: 1 V � a Y eel S S Title: J�.vy v C -e_ ►'1�t t� vt CA �P e ` <br />Signature: Date: 61, l j <br />EHD 22-02-005 lhv 08/10 <br />