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MAY/23/2011/MON 10;21 AM CCCSOLIDATED CON FAX No.120982�35 P.002 <br />4 <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH D8PARTMENT <br />600 East Main Street, Stockton, CA, 95202-3029 . <br />Telephone: (209) 468-3420 .Fim (209) 468-3433 Web: www.sigo`.org/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 />Envirorunental 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 FoiTn, 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 ERD staff time associated with failing to comply by the above noted dates will be billed at <br />the current hourly rate ($122). <br />For this Certification t0 be COITIplete the operator of the site must include. <br />• A statement doctunenting what corrective actions were taken or will be taken.for each violation <br />V Copies of sample results/manifests/training records/other appropriate paperwork, and/or photos <br />verifying corrections <br />• Operator's certification <br />Inspection Date: 140,0 II Inspeeted By: _Th O � <br />.J <br />Facility Address: —75 W , VA -1 pt'Zo VA EPA ID#:CAS I �5 <br />I certify under penaltyf 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 following documentation submitted as proof of compliance FOR <br />EACH VIOLATION and I believe the information to be true, accurate, and complete: <br />Photos N, Paperworlc_Stateznent <br />3. I 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 imprisonnient for known violations. (HSC 25191) <br />Name: tA It or-.- Title: (Q QQ VIWIc�. <br />Simature: ( �,{ /� Date: / .?-.6 <br />EHD 22-02-005 Rdv 08/10 <br />