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SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />600 East Main Street, Stockton, CA 95202-3029 <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sjgov.or <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 (IR) 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 ($98). <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: % 10 � 0 Inspected By:So�. <br />Facility Address: 10 t -1) ' A re w ?c,,,Y-k wo-V EPA ID#: C A 1Z 00WO $ 3 2 8 % <br />Lv.Z-'Vovuro, 614 q 5330 �— <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 />V' Photos 4 ---'Paperwork Statement <br />3. I am authorized to submit this certification on behalf of the Respondent. <br />4. I am awar ha here are sigcant penalties for submitting false information, including the <br />possibili of meor ' risonment for known violations. (HSC 25191) <br />Name: Title: 0,KCX.q C, r <br />Si <br />EHD 22-02-005 Rev 11/07 <br />Date: 7 l id <br />