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RECE.v,E.1) <br /> FEB 2 8 X0,1 <br /> ENVIRONMENTAL HEALTH <br /> Swx,lawQllrtY COUNTY ENVIRONMENTAL <br /> F3NvmoNMrrrAL HEALTH DEPARTMENT <br /> 600 East Main Stree,Stockton.C,4 95202-3029 <br /> Tdopaorie:(209)468-3420 Fax.(209)468-3433 Web:www.s' ov.orWchd <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(13111))address at the top of this form within 35 days of receipt of the <br /> Inspection Report. <br /> AIF corrections to other.violations noted in the attached Inspection Report(IR)or Continuation Form, or <br /> dispputes to any violations,are to submitted using this certification and returned to EHD within 30 days <br /> unress otherwise specified in the Inspection Report. <br /> Note: All EHD staff time associated with fatting to comply by the above noted dates will be billed at <br /> the current hourly rate($.122). <br /> For this certification t0 be complete the operator of the site must include: <br /> • A statement documenting what corrective actions were taken or will be taken for each violation <br /> • Copies of sample results/manifests/training records/other appropriate paperwork,and/or photos <br /> verifying corrections <br /> • Operator's certification <br /> �.✓ttZdv�C (r� SSS$(v <br /> Inspection Date: o r r Inspected By: 4<0 <br /> Facility Address: Ik fs Ef D66rAJo I. EPA ID#: �A4 C1X Z Ir8 155 <br /> 6i0c"v), CA +5Z-62- <br /> I <br /> 5ZGZI certify under penalty of law that: <br /> 1. 1 have corrected the violations specified in the Inspection Report from the above-mentioned <br /> inspection date. <br /> 2. I 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 2519 1) <br /> Name: AjrLc.>J &,fes Title: 16W,�;;vtthOAL-{ M0 t-- <br /> Signature: (44� Date: -2 <br /> EHD 2202-005 Rev 08/10 <br />