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09/12/2008 12:02 2094749151 HAMMER 15 ARCO CAPE �O <br /> SAN JOAQUIN COUNTY SEP 122008 <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 600 East Main Street,Stockton,CA 95202-3029 SAN JOAQUIN <br /> Telephone:(209)468-3420 Far:(209)468-3433 Web:www.sfRoy.org/c1id COUNry <br /> ENVIRONMEWAL <br /> HEALTH DEPARrMgh:1 <br /> RETURN TO COMPLIANCE CERTIFICATION <br /> Any MTNO-R 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 35 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 dgys <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 billed at <br /> the current hourly rate (598). <br /> For this certification 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 Date: 9ZI 42-5: Inspected By: <br /> T— <br /> Facility Address:,.S2.!E;�) LJ. <br /> EPA ID#: CA L <br /> G�c-I c,lz Gtr <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—X,—Paperwork Statement <br /> 1 1 am authorized to submit this certification on behalf of the Respondent. <br /> 4. 1 am aware that there are significant pcnalti.cs for submitting false information, including the <br /> possibility of a fine and/or imprisonment for known violations. (HSC 25191) <br /> Name: Title: <br /> Signature: 44. Date: <br /> EHD 22-02-005 Rev 11 le7 <br />