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r <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEAL-Tfi DEPARTMENT <br /> 304 East Weber Avenue,3rd Floot,Stockton,CA 95202.2708 <br /> Telephone:(209)463-3420 Faw(209)468-3433 Web:www.sj op v•ors/ehd <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(FH D)address at the top of this form within 35 days of receipt of the <br /> inspection.report. <br /> All corrections to other violatians 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 E14D within 60 dans <br /> unless otherwise specified in the IR. "'"" _ <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-.—, ` t` Inspected y: <br /> I <br /> Facility Address: 1 0.2s W tom' EPA. ID#:C AL. ®oc 2.G11 r"I a <br /> o i <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 compliance FOR <br /> EACH VIOLATION and I believe the information to be true,accurate, and complete: <br /> Photos Paperwork <br /> —� ,Statement +I' <br /> 3- I am ar3thorized 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 imprisonment for known violations. (HSC 2519 1) <br /> Name: �a• tc�crntJ" <br /> _ Title:-- V'_ <br /> Si *nature ,. d,. Date- 11 - w- 06 <br /> E ID 22-02-005 Rev 12-04 <br /> __ <br /> 10 39vd 09N3NN3A VSI-1 LZL06EE60Z 89:61 900Z/17Z/IT <br />