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J4/ <br /> SAN JOAQUN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 600 Fast Main Street,Stockton,CA 95202-3029 <br /> Telephone:(209)469-3420 Fax:(209)468-3433 Web:WWW.Sigov-ori OCT 0 9 2008 <br /> SAM 0AGIAN COUNTY <br /> ENVIRONMENTAL <br /> RETURN TO COMPLLkNCE CERTIFICATION HEALTH DEPARTMENT <br /> Any MINOR violations noted in the"Notice to Comply"in the attached Inspection Report must be <br /> Tt submitted corrected within 30 days of receipt of this inspection. This certification form must be submi to the <br /> Environmental 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 Rcport(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 EDD staff time associated with failing to comply by the above noted dates will be billed at <br /> the current hourly rate($98). <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/manifests/training records/other appropriate paperwork, and/or photos <br /> verifying corrections <br /> * Operator's certification <br /> V di., <br /> Inspection Date: ZY Inspected By:-&W�aV <br /> 4 <br /> Facility Address: EPA ID#: IC <br /> I certify under penalty of law that: <br /> 1. 1 have,corrected the violations specified fied 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 XPaperwork-Statement. <br /> t <br /> 3. 1 am authorized to submit this certific,Cion 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: 40740,4,7"b Title: <br /> Signature: <br /> Date <br /> ignaturO: <br />