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NOV. 11.2028 14:20 #4107 P.002 /002 <br /> SAN JOAQUIN COUNTY <br /> ENv1RoNMENi'AL HEALTH DEPARTMENT <br /> 600 Fast MainStreet,Stockton,CA 95202-3029 <br /> Telephone:(209)468-3420 Fax: (209)468-3433 web:www,§.lSov.or /e ehd <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 30 days <br /> unless otherwise specified in the Inspection Report. <br /> Note: All FHT) staff time associated with tailing 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 rccords/othcr appropriate paperwork, and/or photos <br /> verifying corrections <br /> • Operator's certification <br /> Inspection Date: /D- /2 - Inspected By: HdNi�W,+ fV4;Du. <br /> Facility Address: )At Z PerCdrbw4)ct /b R. EPA 1D#: <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 information 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 tun 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: Ter- i2oDl Title: C/co <br /> Signature: Uc ! Date: 4)6kl q o20/D <br /> EHD 22-02-005 Rev 08/10 <br />