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Teleph <br />SAN JOAQUIN COUNTY j �``! <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />600 East Main Street, Stockton, CA 95202-3029 MAY $ 1 2009 <br />(209) 468-3420 Fax: (209) 468-3433 Web: www,s'gov.org/ehd <br />ENVIRONMENT. HEALTH <br />RETURN 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 0f 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 time associated with failing to comply by the above noted dates will be <br />billed at the cur int 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 />• Ooerator's certificatio <br />Inspection Date:— <br />Inspected By: kA V A-tj l= I --U C <br />Facility Address: t b 0 • fFL- EPA ID#: Cp- <br />I certify under penalty f law khat: <br />1. 1 have corrected the violations specified in the Inspection Report from the above-mentioned <br />inspection date. 1. - <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 />L o M A n.1rare <br />t✓Yl Pr m �!2 [ C It 0 U3. 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 Ypv ln_s�I�SS Name: l3 �Z A_AJ C't L-CTitle: &_LA�L- --- <br />Siqnat - Date: < zL <br />C?) e_u : <br />EHD 22-02-005 Rev 08/08 <br />