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10/06/2010 02:19 FAX 2092494642 SSJID <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />600 East Main Street, Stockton, CA 95202-3029 <br />Telephone: (209) 468-3420 Fax. (209) 468-3433 Web: www,sieov.org/ebd <br />RETURN TO COMPLIANCE CERTIFICATION <br />Z004 <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 35 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 EHD within 30 days <br />unless otherwise specified in the Inspection Report. <br />Note: All E13D staff time associated with failing to comply by the above noted dates will be billed at <br />the current hourl1i 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 c,:)rrections <br />• Operator's certification <br />Inspection Date: b 9 - 0.2 — 10 <br />Facility Address : l l o l l <br />I certify under penalty of law that: <br />Inspected By: IY?.A EH 5 <br />a <br />Abnvt GeoAat Pttrolawn <br />EPA ID#: <br />I have corrocted the violations specified in the Inspection Report from the above-mentioned <br />inspection elate_ <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 />Vara�s 1NsP�erray. li�pdr�5 a.�es7S <br />Photos X Paperwork Statement r. need¢d- <br />3. I am authorized to submit this certification on behalf of the Respondent. <br />4. I am aware -hat there are significant penalties for submitting false information, including the <br />possibility c f a fine and/or imprisonment for known violations. (HSC 25191) <br />FNy�Rcnlm�'.�r�L Csm(J1�a��-t <br />Name: Title: &AA 5&vrrydfFjc.c-o__ <br />Date: O <br />EHD 22-02-0051AE, 08/10 <br />