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0 <br /> a'; it 1 5 2010 <br /> ENVIRONMENT HEALTH �-- -4 <br /> SAN JOAQUIN COUNTY ``` FERNIIT/SERVICE3 <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 600 East Main Street, Stockton, CA 95202-3029 <br /> Telephone.(2.09)468-3420 Fax:(209)468-3433 Web:www.s'gov.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 cf'nis 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 Insrpection 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 to be completethe 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 sarnpie res uitslman ifests/training recordslother appropriate paperwork, anchor photos <br /> verifying corrections <br /> • Operator's certification <br /> i Inspection Date:_; � �2, , I In' Inspected By: M <br /> tZI 'C- <br /> Facility <br /> Facility Address: 'b as ---L> , WQl-v K« EPA ID#: CAL y <br /> I certify under penalty of law that: <br /> 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 /> f 14 <br /> 3 ! 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 /> possihility of a fine and/or imp ri70nment for known violations. (HSC 251911 <br /> ( <br /> X Name: X///,- Title: <br /> /'`, Signature: ,'fes Date: <br />