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03/21/2009 13:26 2094732344 MARCH LANE 76 PAGE 02/06 <br /> SAN JaAQUIN 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.sioov.ora/ehd <br /> RETURN TO COMPLIANCE CERTIFICATION <br /> Any MINOR violations noted in the "Notice to Comply" in the affached 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 30 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 submittedusingthis 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 <br /> billed at the current hourly rate. <br /> For this certification to 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/manifest,4/training records/other appropriate paperwork, and/or photos <br /> verifying corrections <br /> • Operator's certification <br /> j C <br /> Inspection Date: 3 0 IO Inspected BY: <br /> o4a / , /EPA ID#: <br /> Facility Address: c� 76�1 — <br /> I certify under penalty of law that: <br /> 1. 1 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 compliance FOR <br /> EACH VIOLATION and I believe the information to be true, accurate, and complete'. <br /> Photos Paperwork Statement <br /> 3. lam authorized to submit this certification on behalf of.the Respondent. <br /> 4. 1 am aware that there are significant penalties for submitting false information, including the <br /> possiWility of a fine and/or imprisonment for known violations. (HSC 25191) <br /> Name. Title:. <br /> Signature: �ate: <br /> Zz <br /> EMI)22-02-005 Rev OEMB <br />