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FROM FAX NO. :12093690153 , Ob. 08 2010 10:08AM P14 <br /> 01/2612010 TUB 14,03 FAX 2094683433 EJC EVID 2002/009 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 800 East Main Street,Stockton,CA 95202-3029 <br /> Telephone:(209)468-3420 Fax,-(209)468,34,33'Web:WW <br /> Igtj <br /> e <br /> RETURN TO COMPLIANCE CERTIFICATION <br /> Any MjhLQR_violations noted in the"Notice to Comply"In the attached Inspection Report must be <br /> corrected wiltNo-AID days of receipt of this Inspection. This certification form must be submitted to the <br /> Environmental Health Department(EHO)address at the top of this form within 30 days of receipt of the <br /> Inspection Report. <br /> All orrectiona t <br /> p 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&Rbtjqdays <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 /> billed at the current hourly rate. <br /> For this certification to 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/manNests/training records/other appropriate paperwork, and/or photos <br /> verifying corrections <br /> • Operator's certification <br /> Inspection Date: <br /> OL Inspected By, <br /> Facility Address;­JLO-EV., r4 Vc�, EPA ID#-. <br /> I certify under penalty of low 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 <br /> _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 26191) <br /> Name, cam. Title: <br /> Date., <br /> WID 22-0?-005 Rev,10109 <br />