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01/06/2011 13:18 9166868545 CONCRETE INC PAGE 03/03 <br />SAN dOAQULN COUNTY <br />ENviRoNMENTA,L HEALTH DEPARTmF-NT <br />600 East Main Street Stockton, CA 95202-3029 <br />,i'BIwhow? (209) 468=3420 Fowl (209) 408=3433 Wob www.ejgev:0HWQhd <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 3.0 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 ,nate ($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:_ M Qre—A , Zo io <br />Inspected By: M e .-%, a I e a 14 a- 4 <br />Facility Address: i5 i E .Lo A:, R ve , La 6� , CAg s z'4e EPA ID#: CA L Ot7o ICI 51-16 <br />I certify under penalty of law that: <br />L 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 information to be true, accurate, and complete: <br />Photos Paperwork X Statement <br />3. 1 am authorized to submit this cenification 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: <br />EHD 22x02-005 Rev 08/10 <br />Title: <br />Date: // 6111 <br />