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2098263$93 ENGINEERING DEPT. 1 44 a.m. 08-27-2009 6/17 <br /> SAN.JIOAQUIN COUNTY <br /> ENVIRONMENTAL.HEALTH DEPARTMENT <br /> 600 East Main street,Stockton, CA 95202-3029 <br /> Telephone:(209)468-3420 Fax:(209)468-3433 web:www sistoy oro/ehd <br /> A ' <br /> RETURNCOMPLIANCE'CERTIFICATION <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 I3epartment(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 dans <br /> unless otherwise specified in the Inspection Report. <br /> Note: All EHD staff time associated with failing to comply by the above noted dates wilVbe <br /> billed at the current hourly rate of$105 (beginning 8/1/09 the hourly rate will be$115). <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 /> ® Ope °s,certification. <br /> Inspection Date: <br /> —6°( Inspected. y. GD <br /> Facility Address:?-7 W pSeMIX � _ EPA-11W YIDti® I✓' 7__q <br /> rA CA®G0� 0003 q7 . <br /> 1 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 Y Paperwork v Statement <br /> 3. 1 am authorized to submit this certification on behalf of the Respondent. <br /> 4. l am aware that there are significant penalties W'submitting false information, including the. <br /> possibility of a fine and/or imprisonment for known violations. (HSC 25191) <br /> Name: �(C�o Title: �S51-s • t -F/ �cIF/�N �'I� <br /> Signature: Date: ,2 <br /> EHD 22-024MB Rev 06= <br />