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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: <br /> -HK <br /> RETURN TO COMPLIANCE CERTIFICATIONAY 0 7 2009 <br /> Any MINOR violations noted in the "Notice to CoMPIY" in the attached Inspection Re663Mb@0UN1Y <br /> corrected within 30 days of receipt of this inspection. This certification form must be I <br /> Pr A <br /> Environmental Health Department(EHD)address at the top of this form within 30 days o; effipRte <br /> Inspection Report. <br /> All corrections to other violations on Form, or <br /> !@_Uons noted in the attached Inspection Report(IR) or Continuation <br /> disputes to any violations, are to be submitted using this certification and returned to EHD within 30 dates <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 /> . <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/manifests/training records/other appropriate paperwork, and/or photos <br /> verifying corrections <br /> operator's certification <br /> Inspection Date: 401 Inspected By: <br /> Facility Address: Za". EPA ID#: <br /> 9wa <br /> 1 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 /> .14-1 <br /> Name: "Mo Title: <br /> Signature: Date: <br />