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TRANSMISSION VERIFICATION REPORT <br /> TIME : 10/19/2012 10:38 <br /> NAME : S,IC EHD UNIT 3 <br /> FAX : 2094683433 <br /> SER. # : BROM717534354 <br /> DATE,TIME 10/19 10:37 <br /> FAX NO. /NAME 915105621354 <br /> DURATION 00:00:20 <br /> PAGE(S) 01 <br /> RESULT OK <br /> MODE STANDARD <br /> ECM <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1868 East Hazelton Avenue, Stockton, California 95205-6232 <br /> Telephone.(209) 468.3420 Fax:(209) 468-3433 Web:www.sigov.org/ehd <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. HSC 25404.1.2(c)(1) <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 EHD within 30 days <br /> unless otherwise specified in the Inspection Report. HSC 25185(c)(3) <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 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 /> Inspection Date: Inspected By: <br /> Facility Address, EPA ID#: <br /> I certify under penalty of law that-- <br /> 1. <br /> hat1. 1 have corrected the violations specified in the Inspection Report from the above-mentioned <br /> inspection date. <br />