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SAN.IOAQVJN COt1NTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 600 East Main Sbvwt,Stockton.CA 95202-3029 <br /> Telepkane,-(209)468-3420 Fax:(209)468-3433 Web:www.si og v ortrd <br /> RETURN TO COMPLIANCE CERTIFICATION <br /> Any MINOR violatio ris noted in the"Notice to Comply"in the attached Inspection Report must be <br /> corrected within 30 Ws of receipt of this inspection. This certification form must be submitted to the <br /> Environmental Heal Department(EHD)address at the top of this form within 35 days of receipt of the <br /> Inspection Report. <br /> All corr c i s too r 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 /> Un cgs <br /> otherwise spe 'feed in the Inspection Report. <br /> Note: All EHD stafl time associated with failing to comply by the above noted dates will be billed at <br /> the current hourly ratio ($122). <br /> For this certlfi ation t0 be COMPIete the operator of the site must include: <br /> • A statement documenting what correctsve actions were taken or will be taken for each violation <br /> • Copies of s ple results/manifests/training records/other appropriate paperwork,and/or photos <br /> verifying con ections <br /> • Operator's certification <br /> Inspection Date: 2 ._ 1 Inspected By: P 4ch <br /> Facility Address: 12 2 !U• i l L Vit, EPA ID#: �,:AL c,cc:'z s z O 2 L <br /> I ✓I.cr , Cil 1753%_ <br /> 1 certify under penalty of law that: <br /> 1. 1 have correct) the violations specified in the Inspection Report from the above-mentioned <br /> inspection date. <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 authoriz 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 ofa fine and/or imprisonment for known violations. (HSC 2519 1) <br /> Name: Title: <br /> Signature: Date: <br /> EHD 22-02-005 Rev 8/10 <br />