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04/27/2011 wED 15:22 FAX 209 $3433 SJC SAD <br />JMQULIUUI <br />SAN JOAQQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />600 E. Main Sc, Stockton, CA, 95202-3029 fgAY® 4 <br />Telophone: (209) 468.3420 F= (209) 468-3433 Web: W.Sj v ehd 20 11 <br />RETURN TO COMPLIANCE CERTIFICATION <br />,Any MIN R violations noted in the "Notice to Comply,, in the attached Inspection Report must be <br />corrected within 3Q dates of receipt of this inspection.. This certification form must be submitted to the <br />Envixonmentai Health Department (EHD) address at the top of this form within 35 days of receipt of the <br />Inspection Report. <br />All corrections to other violations noted in the attached Inspection Report or Continuation Form, or <br />disputes to any violations, are to be submitted using this cextification and returned to ERD ndji 3b days <br />unless otherwise specified in the Inspection Report. <br />Note: All EHD staff time associated with falliing to comply by the above noted dates will be billed at <br />the current hourly gate ($122). <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/rnanifests/training records/other appropriate paperwork, and/or photos <br />verifying corrections <br />® Operator's certification <br />Inspection Date: Inspected By: mt.-,,,,z n4 f a.. M a.; <br />Facility Address: %4-1 0 •MXL4�%S-+— EPA ID#.C'''R' L. S -- <br />IL t Q C.1+ Gu --3 U <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 -w-Paperwork Statem <br />UA4—wk g to ftwe a w►�. <br />3. Iain authorized to submit this certification on beh4if olthe Pteyndent. <br />4. I ami u'f a ere are i x z �n pe ties or subl�hitU wirS in of rmation, including e <br />possibility of a fine and/or imprisonment for know violauon S95191) <br />Name: t3 <br />Title: gtti JL4 jov-&L&40ka <br />Date) t <br />tM <br />