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SAN JOAQUIN COUNTY 0 <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 600 East Main Street, Stockton,CA 95202-3029 <br /> Telephone: (209)468-3420 Fax. (209)468-3433 Web:%vww.sjgoy.org/ehd <br /> RETURN TO COMPLIANCE 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 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 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 billed at <br /> the current hourly rate ($98). <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 formch 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: 41r , Inspected By: <br /> J-- 11-FAJ;R Y <br /> '74000 M. e-lw,(-Xs 0-,VD <br /> Facility Address: e,~,4 EPA ID#: <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 V---'Paperwork— vl<tatement 69- Ar77W-19F D) <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: b1qv_,,0c- e-AAIAI. Title: /,V A),467-CA <br /> Signature: <br /> Date: <br /> P14D ?7-0?-005 Rev 11/07 <br />