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Tcd,§TACY RIVERA Page 3 of 4 2012-11-1503:58:65(GMT) 12097626954 From:RAVINDERSINGH <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 600 East Main Street,Stockton,CA 95202-3029 <br /> relephone:(209)466734420 Fax.(209)468-3433 Web=www.slgov.org/ehd <br /> RETURN TO COMPLIANCE CERTIFICATION <br /> Any MIND R 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)addressat the top of this form within 30 days of receipt of the <br /> InspectionReport. HSC 25404.1.2(c)(1) <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. HSC 25185(0)(3) <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 /> 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/manifestsAraining records/other appropriate paperwork,and/or photos <br /> verifying corrections <br /> • Operator's certification <br /> Inspection Date:_ 15/l�, Inspected By Stacy Rivera <br /> Facility Address:Sa k w c->,� EPA ID#; <br /> SN-C <4� e <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 /> ' <br /> Photos Paperwork -Z-Statement <br /> 3. ] 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) <br /> Name:T41vfn Title:ZZ <br /> __/ c,.�o�. <br /> Signature: Date: /r// /y <br /> EHD 22-02-005 Rev 08/11 <br />