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10:17 209468S433 FIFTH FLOOR PAGE 04 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 3C4 East Weber Avenue,Td Floor,Stockton,CA 95202-2708 <br /> Tdophoise. (209)468-3420 Fax:(209)468-3433 Web: 2_v_.01"eh <br /> RETURN TO COMPLIANCE CERTIFICATION <br /> Any report must M&O inspection r po mu, <br /> ,A violations noted in the "Notice to Comply" in the attached insp C, <br /> corrected NNithin 30 daof receipt of this inspection. This certification formmust be submitted Lo the <br /> Environmental Health Dep em(EHD) address at the top of this form within 35 days of receapt of the <br /> inspection report. <br /> All corrections to other violations noted in the attached Inspection Report (IR) or Continuation I )TM or <br /> disputes to any violations, are to be submitted using i ais certification and returned to BHD yiithin 60 da`,3 <br /> unless otherwise specified in the IR. <br /> For this certification to be complete the operator of the site must include., <br /> • A statement documenting what currective ac ions were taken or will be taken for each violati,)n <br /> • Copies of sample results/manifests/training rt .ords/other appropriate paperwork, and/or photos <br /> I verifying corrections <br /> • Operator's certification <br /> Inspection Date. 31q Inspected By:\j1 _e*,Z,5 <br /> EPA. ID#: 'a <br /> Facility Address: <br /> I certify under penalty of laNv that; <br /> 1. 1 have corrected the violations specified in the Inspection Report ti�orri the above-mentioned <br /> inspection date. <br /> - <br /> 4, 1 have personally examined the folio-wing documentation submitted as pi oof of compliarce FOR <br /> EACH VIOLATION and I believe the information to be true, accural.e, and complete: <br /> _Photos--Paperwork State.le.it <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 /> possibility of a fine and/or impnisc-Lment for known violations. (HSC 25!91' <br /> j a(-A Title: ],,Jjv� <br /> Name:- <br /> Signature-sq_"_ Ek "'Xis Date:' <br /> EHD 22-02-005 Rev 12-04 <br />