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03/28/2008 09:05 2094732344 MARCH LANE 76 PAGE 03/05 <br /> SAN JOAQVIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 600 East Main Street,Stockton,CA 95202-3029 <br /> Telephone:(209)468-3420 Fax:(209)468-3433 Web:W".9i ay.or /Z ehd <br /> RETURN TO COMPLIANCE CERTIFICATION <br /> Any MI"__N R violations noted in the"Notice to Comply"in the attached Inspection Report must be <br /> corrected within 30 clays 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 correctionsto other violations noted in the attached Inspection.Report(IR)or Continuettion Form, or <br /> disputes to any violations, are to be submitted using this certifcabon and returned to EHD within 30 dans <br /> unless otherwise specified in the Inspection Report. <br /> Note: All EHD staff time associated with failing to comply by the above noted dates vvill 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 /> 0 Operator's certification <br /> Inspection. Date: Inspected By: <br /> Facility.A,ddress: d,1 D 1 VJ, N`,P j.„A UeEPA ID#: <br /> I certify under penalty of law that: <br /> 1. I have corrected the violations specified in the Inspection Report from the above-mentioned <br /> inspection date. <br /> 2. 1 have personally examined the following documentation submitted as proof of con.,1pliance FOR <br /> EACH VIOLATION and I believe the information to be trine, accurate, and complete- <br /> Photos Paperwork--X—Statement <br /> 3. I arn,authorized to submit this certification on behalf of the Respondent. <br /> 4. lam aware that there are significant penalties for submitting false information, including the <br /> possibility of a fine and/or imprisonment for known violations. (HSC 2519I) <br /> Name.�'h �iL7 Title: OAJr4-, .r – <br /> Signature: Date: j L <br /> EHD 22-02-005 Rev 11/07 <br />