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• <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTALHEALTN DEPARTMENT � �^ <br />600 E, Main St., Stockton, CA 95202-3029 RECEIVED <br />+ 1R! /a,/� <br />Telephone. (209) 4683420 Fax. (209) 468-3433 Web: www.sigov.ora/ehd <br />OCT 03 2011 <br />RETURN TO COMPLIANCE CERTIFICATIOENVIRONMENTAL Ic s��� <br />Any MINOR violations noted in the "Notice to Comply" in the attached Inspection Report must be <br />corrected within 30 dans 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 wit_hi_n__ 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 ($jZ5). <br />For this certification t0 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 Dater ..,_ . -I _l_._.. ___-_..---... _inspected By -_I <br />Facility Address: aba s�j ba cA(cw oe— J f2_ EPA ID#: CYAC-.(V, ' ,O ) B T)c. <br />_T_2.iAc-L-) i GA <br />I certify under penalty of law that: <br />1. 1 have corrected the violations specified in the Inspection Report from the above-mentioned <br />inspection date. <br />2. 1 have personally examined the following documentation submitted as proof of compliance FOR <br />EACH VIOLATION and I believe the infonnation to be true, accurate, and complete: <br />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: ISCA LV c.C(L)�-ti.Z Title: 1V(:.(4a"( <br />Signature: Date: /0/1ll1 <br />0 EHD 22-02-005 Rev 10-07 <br />