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Oct 25 2010 10: 14 HP LASERJET FAX 209-207-9552 p, l <br /> SAN JOAQUIN COUNTY L) <br /> ENVIRONMENTAL HEALTH DEPARTMENT 0 r j <br /> 600 East Main Street, Stockton,CA 95202-3029 1 5 ZOO <br /> lephome. (209)468-3420 Fox:(209)468-3433 Web:www.sigov.or I gfeh_4,A.4 <br /> RE URN TO COMPLIANCE CERTIFICATION <br /> Any MINOR violations noted in the"Notice to Comply"in the attached Inspection Report must be <br /> corrected within 30 da v� 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 /> i <br /> All corrections to other iviolations noted in the attached Inspection Report(IR) or Continuation Form, or <br /> disputes to any violatio s, are to be submitted using this certification and returned to EHD within 30 days <br /> unless otherwise specifid in the Inspection Report. <br /> HD <br /> Note: All Estaff till a associated with failing to comply by the above noted dates will be billed at <br /> the current hourly rat ($122). <br /> For this certific tion to be complete the operator of the site must include: <br /> 0 A statement umenting what corrective actions were taken or will be taken for each violation <br /> • Copies of samp a results/ma.nifests/training records/other appropriate paperwork, and/or photos <br /> verifying correc ions <br /> • Operator's certi kation <br /> Inspection Date: 0 C4-0 bit- ' 201 O Inspected By:c9t-ct r-q i2i vel <br /> Facility Address: ( }l' L9 ',g6EPA ID#: CA L,QU()9 L1'5565 <br /> I certify under penal of law that: <br /> 1. I have c rrected the violations specified in the Inspection Report from the above-mentioned <br /> inspecti date. <br /> 2. I have rsonall�examined the following documentation submitted as proof of compliance FOR <br /> EACH IOLATION and I believe the information to be true, accurate, and complete: <br /> Photos `� Paperwork_ Statement <br /> 3. I am au orizeItere <br /> submit this certification on behalf of the Respondent. <br /> 4. I am aw thaare significant penalties for submitting false information, including the <br /> possibili of a and/or imprisonment for known violations. (HSC 2519 1) <br /> Name: �� „ Title: L <br /> tore: KDate: Z.5 <br /> EHD 22-02-005 08/110 <br />