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?Wrv-4,1111L SAN JOAQUIN COUNTY <br />'PENVIRONMENTAL HEALTH DEPARTMENO <br />600 East Main Street, Stockton, CA 95202-3029 <br />41 <br />Telephone. (209) 468-3420 Fax. -(209)468-3433 Web: h <br />A <br />R4R,, <br />RETURN TO COMPLIANCE CERTIFICATIONIt." 2010 <br />Any MINOR violations noted in the "Notice to Comply" in the attached Inspection Repotth*, lv �, , lf*�47 <br />corrected within 30 Ls da�of receipt of this inspection. This certification form must be submitwidft'�* <br />Environmental Health Department (EHD) address at the top of this form within 30 days of receipt 6(9'le <br />Inspection Report <br />All corrections to o <br />JbIr violations noted in the attached Inspection Report (IR) or Continuabon 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 of $105 (beginning 8/1109 the hourt . y 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/manffests/training records/other appropriate Paperwork, and/or photos <br />verifying corrections <br />• Operator's certification <br />pe <br />Inspection Date: Inscted BY: <br />Facility Address:- orn &I P6%j 0 EPA [D#: <br />S7VC, A-rZ#'4, C., A- <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 sand fofcolempliancFOR <br />EACH VIOLATION and I believe the information beru, accuratecompte: <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 penaltiesor submitting false information, including the <br />possibility of a fine and/or imprisonment for known violations. (HSC25191) <br />Name: <br />Date'. t73 — <br />EHD 22-02405 Rev OW9 <br />