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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.siaov.org/ehd <br /> RETURN TO COMPLIANCE TIFICTI <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 Inspection Report. <br /> Note: All EHD staff time associated with falling to comply by the above noted dates will be <br /> billed at the current hourly rate. <br /> For this Certification t4 be completethe operator of the site must include: <br /> e A statement documenting what corrective actions were 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 Date: r.A SAO Inspected By: qji 7A AlAr <br /> Facility Address: /5,VO W. Af ina S�. EPA ID#: CAL6000VC7 2.$ <br /> •iso®,J, C4 7536G <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 /> 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 penalties for submitting false information, including the <br /> possibility of a fine and/or imprisonment for known violations. (HSC 25191) <br /> Name: 41,kWZ11drev r Title: i&,_ a✓. Axo of r <br /> Signature: "� Date: -7 cT t 0 <br /> EHD 22-02-005 Rev 10/09 <br />