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03/19/2012 HON I1e10 FAX 2094 433 6JC EHD i�DD4/004 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 600 E.Main St.,Stockton,CA 95202.3029 <br /> 11claphwre:(209)468-3420 Pax:(209)468-3433 Web:wvm sigov otr dJ <br /> RETURN TO COMPLIANCE CERTIFICATION <br /> Any MINQR violations noted in the"Notice to Comply"in the attached Inspection Report must be <br /> corrected within 30 dam 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 oLber viQlatiO,11 Doted in the attached Inspection Report 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 billed at <br /> the current hourly rate(512Q. <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 /> Inspection Date: O&1 1 Inspected By:—Fv-1 "Y vt <br /> Facility Address3100 ' ler _Z 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. 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 /> Photos Paperwork Statement <br /> 3. I am authorized to submit this certification on behalf of the Respondent. <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) g- <br /> Name: �{j YaN AA 1 �t Title: ``V .� C Y rt—tacS7PS <br /> Signature` �� � <br /> EHD 22-02-005 Rev 08/10 <br />