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• I • <br /> i <br /> SAN JO.,QUIN COUNTY <br /> ENVIRONMENTA..HEALTH DEPARTMENT <br /> 600 E.Main St,Stockton,C)I 95202-3029 <br /> Telephone:(209)468-3420 Far., (209)468-3433 Web:www.sieov.orglebd <br /> I <br /> RETURN TO COMI LLANCE CERTIFICATION <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 inspect;on. 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 art,ached Inspection Report or Continuation Form, or <br /> disputes to any violations, are to be submitted usi rg this certification and returned to EHD within 30 days <br /> unless otherwise specified in the Inspection Repo-t. <br /> Note: All EHD staff time associated with failvi tg to coml'I)ly 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/trainii rg records,/other appropriate paperwork, and/or photos <br /> verifying corrections <br /> • Operator's certification <br /> Inspection Date: I Inspected By: <br /> Facility Address:/�S� Cin�'!��' EPA ID#: ea `/2.252 <br /> I certify under penalty of law that: <br /> 1. I have corrected the violations specified in the Inspection Report from the above-mentioned <br /> inspection date. <br /> 2. I have personally examined the followisi g documetrtation submitted as proof of com eliance FOR <br /> EACH VIOLATION and I believe the information to be true,accurate,and comp <br /> photos Paperwork Statement <br /> 3. I am authorized to submit this certification on behalf of the Respondent. <br /> 4. lam aware that there are significant per allies for submitting false information,including the <br /> possibility of a fine and/or imprisonrnma for knom+n violations. (HSC 25191) <br /> Name: of�G� Title:SU U7 c 1W2 <br /> _ Date: - <br /> Signature: <br /> EHD 22-02-005 ev 10-07 <br /> I'd £LZ60666OZ out se01naaS �j dLbZL 11 60 9azj <br />