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12/04/2009 FRI 15: 05 FAX 2094-4533433 SJC EHD 0001 <br /> ********************* <br /> *** FAX TX REPORT *** <br /> ********************* <br /> TRANSMISSION OK <br /> JOB NO. 3054 <br /> DESTINATION ADDRESS 99573628 <br /> PSWD/SUBADDRESS <br /> DESTINATION ID <br /> ST. TIME 12/04 15: 04 <br /> USAGE T 01' 20 <br /> PGS. 1 <br /> RESULT OK <br /> 002454 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 600 East Main Street, Stockton, CA 95202-3029 <br /> Tole None:(209)468-3420 Fax:(209)468-3433 Web:www.sigov.org/ehd <br /> RETURN TO COMPLIANCE CERTIFICATION <br /> Any MINOR violations noted 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 30 days of receipt of the j <br /> Inspection Report. <br /> All corrections to other violations 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 specifi d in the Inspection Report. <br /> Note: All EHD staff ti a associated with tailing tYY o comp) b the above noted dates will be <br /> billed at the cu rent hourly rate. <br /> For this certlfic tion to be complete the operator of the site must include: <br /> i <br /> ® A statement documenting what corrective actions were taken or will be taken for each violation <br /> • Copies of sample reults/manifests/training records/other appropriate paperwork, and/or photos <br /> verifying corrections <br /> • Operators certifica6n <br /> Inspection Date: Inspected By: <br /> Facility Address: EPA ID#: <br /> I certify under penalty f 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 e amined 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 /> 3. 1 am authorized to submit this certification on behalf of the Respondent. <br /> I <br /> 4 1 am awnra that thaw ara cinnifinnnt nannitiaQ fnr ci ihmiffinn folco infnr +;, <br />