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2008/-1UL/14/MON 03: 34 PM P. 003 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 600 E.Main St.,Stockton,C.A.95202-3029 <br /> Teleph.one. (209)468-3420 Face:(209)468-3433 Web:=.qjgov.orgLe <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 or Continuation Form, or <br /> disputes to any violations, are to be submitted using this certification and returned to FHD within 30 days <br /> unless otherwise specified in the Inspection Report. <br /> Note: AD ERD 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 complete the operator of the site must include: <br /> s A statement documenting what corrective actions were taken or will be taken for each violation <br /> 0 Copies of sample results/manifests/training records/other appropriate paperwork, and/or photos <br /> verifying corrections <br /> 9 Operator's certification <br /> Inspection Date: 0 (a /0 q ldmo Inspected By:TW len r/U91 <br /> ULS <br /> Facility Address: -;2_S7D/ lVayv "br EPAID#:. OA L 000039s�1 <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 /> V1 'Photos Paperwork V1 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 /> �,w_n(orr o-F <br /> Name:-AA Tine: ,&M v e5 <br /> Signature: Date: <br /> -/' off' <br /> BHD 2202-005 Rev 10-07 <br />