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002454 MD <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 600 East Main Street, Stockton, CA 95202-3029 AU6 0 4 C01� <br /> Telep.',ona:(209) 468-3420 Fax: (209)468-3433 Web:www.sjgov.org/ehd ENVIPUNKEN(HEALTH <br /> PERMIT/SERVICES <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 /> I <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 EHD staff time associated with failing to comply by the above noted dates will be <br /> billed at the current hourly rate. <br /> I <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 /> i <br /> • <br /> Operator's certification <br /> Inspection Date: `7 Inspected By:17 <br /> Facility Address: EPA ID#: �I LC''C_' !�-L-I <br /> I certify under penalty of law that: j <br /> 1. 1 have corrected 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 /> I <br /> Photos x Paperwork Statement <br /> 3. 1 am authorized to submit this certification on behalf of the Respondent. <br /> I <br /> 4 1 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- I V ( kA S Title: U RWCA9 ,S <br /> Signatur Date4 <br /> EHD 22-02-005 Rev 08/08 <br />