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APR-30-2010 FRI 05: 23 PMP. 003 <br /> SAN JOAQUIN 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. i gv.ora/ehd <br /> _. . RETURN TO COMPLIANCECERTIFICATION <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 associated with failing to comply by the above noted dates will be <br /> bulled at the.current hourly rate. <br /> For this Certification t0 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 photo$ - <br /> verifying corrections <br /> • Operator's certification <br /> Inspection Date: Inspected By: ra.L c• <br /> Facility Address: EPt LW i0 EPA I <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 /> . <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 bye, accurate, and complete: <br /> Photosy Paperwork !r' Statement <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 /> Rn't LA Title: <br /> Signature:. Date: '2.e� �• <br /> EHD 22-02-005 Rev 101D9 <br /> I <br />