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Inspection Date: Co( 2._Q/1 Inspected By: Rdocrt O 2( z_ <br />Facility Address: `'?S .v\rI1 C-U3e EPA ID#: <br />Ci\k, c? 5 2'1 9 <br />I certify under penalty of law that: <br />I have corrected the violations specified in the Inspection Report from the above-mentioned <br />inspection date. <br />I have personally examined the following documentation submitted as proof of compliance FOR <br />EACH VIOLATION and I [Der ve the informati n to be true, accurate, and complete: <br /> <br />Photos <br /> <br />Paperwork y S,ement <br /> <br />I am authorized to submit this certification on behalf of the Respondent. <br />I 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: r 6j/vz.t3 Title: <br />Date: ,_7(') / Signature. <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT REC <br />600 East Main Street, Stockton, CA 95202-3029 <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sIclov.orq/ehd JUL 18 WIZ <br />HeserIVIMMTNE. <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 (EHD) address at the top of this form within 30 days of receipt of the <br />Inspection Report. <br />All corrections to other violations 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 END within 30 days <br />unless otherwise specified in the Inspection Report. <br />Note: All EHD staff time associated with failing to comply by the above noted dates will be <br />billed at the current hourly rate. <br />For this certification to 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 />EHD 22-02-005 Rev 10/09