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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 600 East Main Street,Stockton,CA 95202-3029 <br /> Tel phone. (209)468-3420 F�09)468-3433 Web:www.sjgov.org/chd <br /> RET 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 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 35 days of receipt of the <br /> Inspection Report. t r..,. <br /> All corrections to other vi latlons noted in the attached Inspection Report(IR)or Contin; <br /> disputes to any violations, are to be submitted using this certification and returned to EHD within 30 days <br /> unless otherwise specifie in the Inspection Report. AU' - 12011 <br /> Note: All EHD staff tim associated with failing to comply by the above noted dates willlWOUNTY <br /> r ho A+ -NTAL <br /> the current hourly rate( 122). HEALTH DEPARTMENT <br /> For this Certif Cat 021 t0 be completethe operator of the site must include: <br /> ng what correctve acten or wen <br /> • A statement doc entiiions were taken be taken for each violation <br /> • Copies of sampleresults/manifests/training records/other appropriate paperwork, and/or photos <br /> verifying correcti ns <br /> • Operator's certification <br /> Inspection Date: Inspected By: TH) T- ) I� W <br /> -/a ` a ems. //ZZ J:f <br /> Facility Address: 5i f.,4 EPA ID#: <br /> 915'-3 c14 <br /> I certify under penalty of law that: <br /> 1. 1 have corrected th violations specified in the Inspection Report from the above-mentioned <br /> inspection date. <br /> 2. 1 have personally a Kamined the following documentation submitted as proof of compliance FOR <br /> EACH VIOLATIC N and I believe the information to be true,accurate, and complete: <br /> Photos Paperwork Statement <br /> 3. I am authorized to ubmit this certification on behalf of the Respondent. <br /> 4. I am aware that thja <br /> are significant penalties for submitting false information, including the <br /> possibility of a finnd/or imprisonment for known violations. (HSC 25191) <br /> Name: L Title: �'i25�c�L--.✓ <br /> Signature. PWDate: <br /> EHD 22-02-005 Rev 08/10 <br />