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Yfi <br /> SAN JOAQUIN OUNTY i <br /> ENVIRONMENTAL HE LTH DEPARTMENT <br /> 600 East Main Street, Stockton, CA 95202-3029 <br /> Telephone:(209)466-3420 Fax:(209)466-3433 e :www.sigov.or /g ehd <br /> CERTIFICATIONRETURN TO COMPLIANCE <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 associate withail comply theabove note dates will be <br /> ill the current hourly rate o '1 (bei inning 8/1/09 the hourly rate will be$115). <br /> For this i I ion to be COMP16tO the operator of the site must include: - <br /> e A statement documenting what corrective actions wade 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 Inspected Mzt" <br /> Facility res : —� EPA 1D#: <br /> certify under penalty of law that: C <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-tib-be true, accurate, and complete: ---- <br /> Photos PaperworkStatement <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:_ /1 Title: <br /> ignatu ate: / <br /> EHD 22-02-005 Rev 06/09 <br />