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0 <br />OCT -M-2005 12:26 FRO�1:ROLAND ENAS 4088421287 TO:19096283380 P:4/4 <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />.404 East Weber Avenue, 3'd Floor. Stockton, CA 95202-2708 <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: <br />1 <br />v vifif <br />P - -•- ra <br />/ ����'ij <br />RETURN TO COMPLIANCE CERTIFICA6�"' <br />AnY —M—W-09 viottrons noted in the "Notice to Comply" in the attached inspection report must be <br />of receipt of this inspection. This certification form must be submitted to thc� <br />Environmental Health Department (EHD) 4ddress at the top,of Uiis form within 35 days of re' <br />inspection report. ceipt of t <br />LIL, 1 E 2 E Tl =0 <br />fAiMlffil= X L <br />For this certification to be completethe operator of the site must include: <br />0 A staterrient documenting what corrective actions were taken or will be taken for each violatiOT, <br />• Copies of sample results/manifests/training records/other appropriate paperwork, and/or photos <br />verifying corrections <br />• Operator's certcation <br />Inspection Date:: <br />ff Inspected By: <br />Facility Address: <br />o PA ID: <br />1 certify �,mder penalty of lawt'qhaltr;W/ <br />L I havc coKTected the violations specified in the Inspection Report from the above-mentioned <br />inspec,tion date, e j <br />2. 1 have Personally examined the following documentation submitted a" Proof of compliance FOR <br />EACH VIOLATION and I believe the information to be true, accurate, and complett:: <br />Photo$ aperwork <br />Statement <br />3. I= authorized to submit this certcation 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 imprisorunent for known violations. (HSC 2519 1) <br />Name: <br />Title: <br />3 <br />19 SWE I WON I <br />5NGWZ11YTr �M <br />