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I <br /> 0 <br /> SAN JOAUIN COUNTY i <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 600 East Main Street, Stockton, CA 95202-3029 <br /> Telephone.(209)468-3420 Fax.(209)468-3433 Web:www.siaov.or /g ehd <br /> COMPLIANCERETURN TO I I I <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 associated with failing to comply by the above noted dates will be <br /> billed at the current hourly rate o 105 (beginning 8/1/09 the hourly rate will be$115). <br /> C this Ifi tl n to be completethe operator of the site must include: <br /> e A statement documenting what corrective actions were taken or will be taken for each violation <br /> e Copies of sample results/manifests/training records/other appropriate paperwork, and/or photos <br /> verifying corrections <br /> e Operator's certification <br /> Inspection Da : Inspected : <br /> Facility Address: 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 a fine and/or imprisonment for known violations. (HSC 25191) <br /> Name: Title: <br /> Signature: Date: <br /> EHD 22-02-005 Rev 08!09 <br />