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jul.20, 2012 4.,33PM Sa oaqu'in County <br />- zr .," fy&-t,! —,IVR-4IV <br />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 />;:.O. -U!" COUNTY <br />RETURN TO COMPLIANCE CERTIFICATibN 10'Ni�lENTAL. <br />HEALTH H DEPAsrMENT <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 />E=nvironmental 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 curent hourly rate. <br />For this ceriificotion to be complete the operator of the site must include- <br />* A statement dAcumenting what corrective actions were taken or will be taken for each violation <br />• Copies of sample r�esulWrnsnifests/training records/other appropriate paperwork, and/or photos <br />verifying corrections <br />• Operator's certification p <br />Inspection Date: _-Z [nopected By: 1 U, <br />Facility Address: l►' �y 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 personal) examined the following documentation submitted as proof of compliance FOR <br />EACH VIOtATI N and I believe the information to be true, accurate, and complete: <br />Photos Paperwork �tatement <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: f� A Lr !r J-1 '" &t LZ:'-- Title: <br />Signature: Data: 7 I "q Z'�— <br />BID 22.02-005 Rev 0411802 <br />