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SAN .10AQUIN COUNTY <br />RECEIVED <br />ENVIRONMENTAL HEALTH DEPARTMENT DEC 13 2010 <br />600 East Main Street, Stockton, CA 95202-3029 <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sigov.org/ehd <br />ENVIRONMENTAL HEALTH' <br />PERMIT/SERVICES <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 30 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 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 <br />billed at the current hourly rate. <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 Date: 12_ o7. 2olp Inspected By: J_ FF LVON6 <br />Facility Address: 16 t . 14/4 bltVG W,4 -,Y <br />5 �OcKi014l CA 7S2ot4 <br />I certify under penalty of law that: <br />EPA ID#: CAL 000 3� 26'06 <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 information to be true, accurate, and complete: <br />�KO laCO 1�E lmrV0[CC- (S ATrAcl1_--7) • (etn+cR(CA" VALL.c y� <br />y Photos Paperwork Statement <br />3. 1 am authorized to submit this certification 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: cykc/S Title: 6W1`46 --k <br />Siqnature: /11( /jV/1111 Date: /�2 - 10- 1(j/0 <br />EHD 22-02-005 Rev 10/09 <br />