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SAN JOAQUIN COONTYtiE u_ � ENVIRONMENTAL HEALTH DEPARTMENT 600 East Main Street, Stockton, CA W b' 3 N siaov.ora/ehd OCT 2 3 2009 Telephone: (209) 46a-3420 Fax:(209) sw 507M= ETH DEDAIRTMENT RETURN TO COMPLIANCE CERTIFICATION Any MINOR violations noted in the "Notice to Comply" in the attached Inspection Report must be corrected within 30 da sof receipt of this inspection. This certification form must be submitted to the Environmental Health Department (EHD) address at the top of this form within 30 days of receipt of the Inspection Report. n Form, or All corrections to other violations noted in the attached)nceecti0i ion and reReport turned to EHD within 30 days disputes to any violations, are to be submitted using unless otherwise specified in the Inspection Report, Note: All EHD staff time associated with failing to comply by the above noted dates will be billed at the current hourly rate. For this certification t0 be complete the operator of the site must include: • A statement documenting what corrective actions were taken or will lltb paperwork,pfrach viand/ool hotn o • Copies of sample results/manifests/training recordslother appropriate verifying corrections • O erator's certification inspection Date: O 9 Inspected By: rn ` � UA Facility Address�� ( 4EPA ID#: I certify under penalty of law that: 1. I have corrected the violations specked in the Inspection Report from the above-mentioned inspection date. Ilowing proof of 2 EACH VIOLATION personally examined I believe the information tobe true,on accurateeand complet compliance FOR Photos—X--Paperwork Statement 3. 1 am authorized to submit this certification on behalf of the Respondent. 4. 1 am aware that there are significant penalties for submitting false information, including the poss- ' f a fine s /or 1prisonment for known violations. (HSC 25191) Title: Nam Date: Signature: C.�--