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08/22/2012 11:42AR FAX 2093330318 RSI4 CORP 0401/0008 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL,HEALTH DEPARTMENT <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> Telephone.(209)468-3420 Fax.(209)468-3433 Web..www.§jgoy.oq1tqk1d <br /> ..:. & <br /> RETURN TO COMPLIANCE CERTIFICATION AUG 2 2 2012 <br /> Any MINOR violations noted in the"Notice to Comply" in the attached Inspection Report must be,,,:.. ,f _ <br /> corrected_within.3C1_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. HSC 25404.1.2(c)(1) <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. HSC 25185(c)(3) <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 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: - 2 Inspected By: MUf4JAPPA+ 41 . <br /> 60105• ke m <br /> Facility Address: fi " .---_ _ EPA I : <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. 1 am 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�-afifine and/or imprisonment for known violations. (MSC 25191) <br /> Name: 1 '� �-. f + /'� Title: ?11-2" <br /> Signature: Date: 0 Fes' <br /> EHO 22.02408 Rev 08/11 <br />