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03/21/2005 14: 59 2099829' 5 JOE5 TRAVEL PLA7A PAGE 02 <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)468-3433 Web:v_vww.siRay.or 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 .Realth 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 END within 60 days <br /> unless otherwise specified in the Ill_ <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:,azlay1a5 _ Inspected By I , <br /> Facility ,A,ddress:1 Q( 3. EPA ID#: Ca Incil_f51 <br /> I certify under penalty of law that: <br /> 1. I have corrected the violations specified in the Tnspection 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 VIOLATTON and I believe the information to be,true, accurate, and complete: <br /> –X—Photos paperwork Statement <br /> 3. I am 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: lc iii rICR <br /> Signature: Date: <br /> EHD 22-02-405 Rev 12-04 <br />