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SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />600 E. Main St., Stockton, CA 95202-3029 <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sigov.org/chd <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 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. <br />Note: All EHD staff time associated with failing to comply by the above noted dates will be billed at <br />the current hourly rate ($122). <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: uSs" VC ) 12,00.— Inspected By: 1\Mv6 affk. NoadM <br />Facility Address: WS; CD\ Oil 9-vi4 EPA ID#: C Pr12_ 0 CO 2'1 O 07 <br />wieto, )-2(0(/ <br />I certify under penalty of law that: <br />I have corrected the violations specified in the Inspection Report from the above-mentioned <br />inspection date. <br />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: <br /> Photos V Paperwork ‘7. Statement <br />I am authorized to submit this certification on behalf of the Respondent. <br />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 /> <br />Name:fY\..b.e(Liti) 1,)Q \\_S <br /> <br />Title: \".141-- eckS - e(` OW- IYIAnkr <br /> <br />Date: 1/11 <br /> <br />Signature: <br />EHD 22-02-005 Rev 08/10 <br />