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11,x'2112008 13:47 FAX 2055305525 DB 'WESTERN CALIF. �r�r2;00C; <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />600 East Maim Street Stockton, CA 95202-3029 `• <br />Televhene. (209) 468-3420 Fax: (209) 468-3433 Web: www.siizov.org/ehd <br />• r <br />RETURN TO COMPLIANCE CERTR ICA.TION <br />t. <br />Any MINQR violations noted in the "Notice to Comply" in the attached- Inspection Report must be <br />coggZ2d 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 29 ons 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 3 <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 billed at <br />the current hourly rate ($98). <br />Forthis certification to be complete the operator of the site must include: '% <br />• A -statement documenting what corrective actions were taken or will betaken 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 />w <br />Inspection Date: inspected By: Ltl <br />y Facility Address: Z6 50 W U/6_" EPA ID#: <br />I certify under penalty of law that: <br />1. I have corrected the violations specified in the Inspection Report from the above-mentioned <br />inspection date. <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 />Photos Paperwork _ Statement <br />3. I am authorized to submit this certification on behalf of the Respondent. <br />4. Yam -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 />.-� <br />Name: Title:109 <br />l. <br />Date: ikk- <br />