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Sep 11 06 05:20p <br />Haji Bayanzay <br />• <br />20 .1 <br />65-0525 p <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />304 East Weber Avenue, 3" Floor, Stockton, CA 95202-2708 <br />Telephone (209) 468-3420 Fax: (209) 469-3433 Web. www.sieov.ore/ehd <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 35 days of receipt of the <br />inspection report. <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 60 days <br />unless otherwise specified in the IR- <br />For this certification t0 be COMPIete 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/ftaining records/other appropriate paperwork, and/or photos <br />verifying corrections <br />Operator's certification <br />Inspection Date: n ur - - E- ;- Inspected By: :''n' r ,L� .. .- . - ` <br />' <br />Facility Address: -93C (' [-� c1t-1�Z, �U t� EPA ID#: <br />S�L1C-`L''-I C1 ySLCI, <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 infonmation to be true, accurate, and complete: <br />V -, Photos - Paperwork t/ Statement <br />3. lam authorized to submit this certification on behalf of the Respondent. <br />4. I 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: Title: s.; <br />Date: ; - e �- - (- ( <br />