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jul. 20, 2012 4 33 PM Sa oapuln County No, 0165 P. 1 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT � <br /> I'1866 East Hazelton Avenue, Stockton,California 9520$-6232 r �' <br /> Telephone:(209)469-3420 Fax:(249)468-3433 Web:wwWAq�b�.orq/ehd <br /> JUL 20 <br /> RETURN TO COMPLIANCE CERTIFICATibN -I64I !,ENTAL. <br /> I11tAL HDEPAsrMENT <br /> Any MINPR vlolations noted in the "Notice to Comply' in the attached Inspection Report must be <br /> corre ®�l within 30 dav�of receipt of this inspection. This certlflcatian form must be submitter!to the <br /> Environmental Health Department(EHD)address at the top of this form within 30 days of receipt of the <br /> Inspection Report. HSC 25404,1.2(c)(1) <br /> All g9rrections to qtbgr vi' lations noted in the attached Inspection Report(IR) or Continuation Form, or <br /> disputes to any violation , are to be submitted using this certification and returned to EHD within 30 days_ <br /> unless otherwise Specified in the Inspection Report_ HSC 25185(c)(3) <br /> Note: All EHD staff time associated with failing to comply by the above noted dates will be <br /> trilled at the Gu rent hourly rate. <br /> For this ceftiflcotion to be complete the operator of the site must include: <br /> . A statement dAcumenting what corrective actions were taken or wiil be taken for each violation <br /> • Copies of sample reuIWrnanife$ts/training records/other appropriate paperwork, and/or photos <br /> verifying corrections <br /> • Operator's certification IV <br /> Inspection Date: _ -Z`� — 1 Z Inspected By: 1 �' <br /> Facility Address: l ► '�y ' G b'1Z A-J" EPA ID#: <br /> Iertify under penalty of law that: <br /> ull have corrected Ithe violations specified In the Inspection Report from the above-mentioned <br /> inspection date. <br /> 2. 1 have personallyexamined the following documentation submitted as proof of compliance FOR <br /> EACH VIOLATIN 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. Ism awaro 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: J-I-- `" Ct LZ— Title: <br /> Signature: Date: l 1- t-X— <br /> BID <br /> X -BID 224)2.005 Rev 0411902 <br />