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SAN JOAQUIN COUNTY 1-01ECUMEDD <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 600 E.Main St., Stockton,CA 95202-3029 jUN 0 4 2010 <br /> Tele one:(209)468-3420 Fax:(209)468-3433 Web:www.s' o iNT <br /> ElivifluPE HEALTH <br /> RETURN TO COMPLIANCE CERTIFICATION <br /> Any MINOR violations n ted in the"Notice to Comply"in the attached Inspection Report must be <br /> corrected within 30 days of receipt of this inspection. This certification form must be submitted to the <br /> Environmental Health Department(EHD) address at the top of this form within 35 days of receipt of the <br /> Inspection Report. <br /> All corrections to other violations noted in the attached Inspection Report 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 tim associated with failing to comply by the above noted dates will be billed at <br /> the current hourly rate ( 115). <br /> For this certiflcat on t0 be complete the operator of the site must include: <br /> • A statement docuenting what corrective actions were taken or will be taken for each violation <br /> • Copies of sample esults/manifests/training records/other appropriate paperwork, and/or photos <br /> verifying correctio s <br /> • Operator's certific tion <br /> Inspection Date: L/ Z al Inspected By: 3-0 f-4 IAJ11rV(7 <br /> Facility Address: 19 0 S F L n EPA ID#: CA L OU U Z &?,N <br /> I certify under penaltjeamined <br /> law that: <br /> 1. I have corrected tiolations specified in the Inspection Report from the above-mentioned <br /> inspection date. <br /> ,, 2. I have p <br /> 0ersonally the following documentation submitted as proof of compliance FOR <br /> EACH VIOLATIand I believe the information to be true, accurate, and complete: <br /> Photos_Paperwork Statement <br /> 11/ 3. I am authorized to ubmit this certification on behalf of the Respondent. <br /> �4. I 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 /> Name: M zjz V' Title: 0 14 <br /> :�)Signatu �� �AA�- Date: D(�— 3 - �D <br /> EHD 22-02-005 Rev 10-07 <br />