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SAN JOAQUIN COUNTY �� �a <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> ED <br /> 600 Fast Main Street, Stockton, CA 95202-3029 <br /> Telepf�one:(209)468-3420 Fax:(209)468-3433 Web:www.siaov.o&ghd MAY 14 2013 <br /> z 9ROi'VIENTAL <br /> HEALTti Di._PF;R R0,ENT <br /> RE URN TO COMPLIANCE CERTIFICATION <br /> Any1111 I _NO„R_violations noted in the "Notice to Comply In the attached Inspection Report must be <br /> corrected Within 30days 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 <br /> Inspection Report. HS 25404.1.2(c)(1) <br /> All corrections to otherto atioM 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 withi 30 days, <br /> unless otherwise specifiled In the Inspection Report. HSC 25185(c)(3) <br /> Note: All EMD staff I Ime associated with failing to comply by the above noted dates will be <br /> billed at the c irrent hourly rate. <br /> For this certifi tlorl to 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 esufts/manifests/training records/other appropriate paperwork, and/or photos <br /> verifying corrections <br /> e Operator's certification <br /> Inspection Date: /q l Inspected By:� <br /> Facility Address: % ' EPA IDtlt: CN- D 0 0 o�i) P9, _V <br /> I certify under penalty of law that: <br /> 1. 1 have correct the violations specified in the Inspection Report from the above-mentioned <br /> inspection dat . <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 /> 3. 1 am authorized to submit this certification on behalf of the Respondent. <br /> 4. 1 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.ALm Lk7yy" Title: tj4 f T- <br /> Signature: Date: <br /> EMD 22-02-005 Rev 09111 <br />