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San Joaquin County <br /> y C VV II!)", <br /> Environmental Health Department <br /> 3 D4 E. Weber Ave., Third Floor Stockton CA 95202 MAR 7 <br /> (209) 468-3420 Phone • (209) 468-3433 Fax <br /> I:Nvwcw N1, t <br /> PERMWSEKICE"' <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 viol tions 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 M. <br /> For this certification t0 be Complete the operator of the site must include: <br /> • A statement docum nting what corrective actions were taken or will be taken for each violation <br /> • Copies of sample re ults/manifests/training records/other appropriate paperwork, and/or photos <br /> verifying correction <br /> • Operator's certificat on <br /> Inspection Date: 3 D Inspected By: 'Zm aQ.u-) <br /> Kr. cost <br /> Facility Address: r EPA'ID#: C f9 k 000o2!1.1� .3 <br /> I certify under penalty o law that: <br /> 1. 1 have corrected the iolations 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:fo <br /> Photos ✓ Paperwork Statement <br /> 3. 1 am authorized to su mit 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: ROP P Title: AePsf c e <br /> Signature: Date: <br /> November 2004 <br />