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SAN JOAQUIN COUNTY <br /> ENVMONMMTAL HEALTH DEPARTMENT <br /> 600 East Main Sb eet,Stockton.CA 95202-3029 <br /> Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.si ole v.orp/qhd <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 dgys 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 /> Al"tionReport. <br /> l to other violations noted in the attached Inspection Report(IR)or Continuation Form, or <br /> disputes to any violations,are to submitted using this certification and returned to EHD within 30 days <br /> unless otherwise s ci red in the Inspection Report. <br /> Note. All EHD staff Ime associated with failing to comply by the above noted dates will be billed at <br /> the current hourly ra a($122). <br /> For this Certlfi ation t0 be COMPIetC the operator of the site must include: <br /> + A statement documenting what corrective actions were taken or will be taken for each violation <br /> a Copies of sample results/manifests/training records/other appropriate paperwork,and/or photos <br /> venfying corr�Ctions <br /> Operator's certification <br /> &4,,bene a 3-N!5'- <br /> Inspection Date: 2 g " l Inspected By: Hr� <br /> Facility Address: / 22 IVj- 1/41L 5t, EPA ID#: f,L Vca2Jz 0 z <br /> cA °r 5�,7(m <br /> I certify under pen4ity of law that: <br /> 1. 1 have correct e the violations specified in the Inspection Report from the above-mentioned <br /> inspection date,) <br /> 2. 1 haveersonaljy examined the following documentation submitted as proof of compliance FOR <br /> EACH VIOLAf1ON and I believe the information to be true,accurate,and complete: <br /> _Photos -1-1m <br /> Paperwork Stateent <br /> 3. 1 am a thorized to submit this certification on behalf of the Respondent. <br /> 4, lam aware that ere are significant penalties for submitting false information,including the <br /> possibility of a ne and/or imprisonment for known violations.(HSC 2519 1) <br /> Name: C'` Title: L%r,✓.rcn nze�� l N�a►�<<5 c <br /> Signature: Date: <br /> EHD 2202-005 Rev 08 10 <br />