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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 600 East Main Street, Stockton,CA 95202-3029 <br /> Telephone:(209)468-3420 Fax:(249)468-3433 eb._ .sioov.org/ehd <br /> -CERTIFICATIONRETURN TO COMPUANCE <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 (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 submitted using this certification and returned to EHD within 30-days <br /> unless otherwise specified in the Inspection Report. <br /> Note: All EHD staff time associatewith,. d falling to comply y the above,noted dates will be <br /> billed ait the current hourly rate of 105 (beginning 8/1/09 the hourly rate will be$115). <br /> For this ii tl to be completethe 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 ate: Inspected k; <br /> 1A I <br /> Facility r s : ems`_ - i I f .7 EPA I _ : - 0^ -Ej-Z <br /> 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. I 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 a fine and/or imprisonment for known violations. (HSC 25191) <br /> Name: "r—%: Title; <br /> Signature. --_ _. .. : -_ -__ Date: 1 <br /> EHD 22-02-005 Rev 06109 <br />