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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 600 East Main Street, Stockton, CA 95202-3029 MAY $ 1 2009 <br /> Teleph ne: (209) 468-3420 Fax: (209)468-3433 Web:www,s'gov.org/ehd <br /> ENVIRONMENT. HEALTH <br /> PF8MIjjSEBV1QES <br /> RET RN TO COMPLIANCE CERTIFICATION <br /> Any MINOR violations not d in the "Notice to Comply" in the attached Inspection Report must be <br /> corrected within 30 days f receipt of this inspection. This certification form must be submitted to the <br /> Environmental Health De artment (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 the Inspection Report. <br /> Note: All EHD staff ti a associated with failing to comply by the above noted dates will be <br /> billed at the cur nt hourly rate. <br /> For this Certifica ion t0 be Complete the operator of the site must include: <br /> • A statement docume ing what corrective actions were taken or will be taken for each violation <br /> • Copies of sample res Its/manifests/training records/other appropriate paperwork, and/or photos <br /> verifying corrections <br /> • Operator's certificatio <br /> Inspection Date: Inspected By: kA V A-tj 6 L-Uryll <br /> C <br /> Facility Address: t b 0 EPA ID#: Cp- <br /> I certify under penalty f 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 /> L'5) <br /> Photos Paperwork Statement <br /> L o M P,(,J �rare <br /> r - t�✓Yl Pr m �!2[C It 0 U <br /> 3. I am authorized to is certification on behalf of the Respondent <br /> 4. 1 am aware that thegnificant penalties for submitting false information, including the <br /> ossibilit of a fine rison�n fQ�kn w iolp� SC 251p Y p(� vns� I� {� -, -Name: l3 � Z A_AJ C't L-CTitle: &_LA�L- --- <br /> Signat - Date: zC <br /> EHD 22-02-005 Rev 08/08 <br />