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III CJ,31 LCJCJ:1 OC. LO 404ulJo rviv-Lmui it-riIHL rfCHLIri r-HUL YJl SAN JOAQUIN CouN-Y ENVIRONMENTAL HEALT11 DEPARTMENT 304 East Weber Avenge,3'4 F1001, Stockton, CA 95202-2708 Telephone:(209)468-3420 Fax.(209)468-3433 Web:www,s' ov EVYED NUii - 7 2005 RETURN TO COMPLIANCE CERTIFICAXWNT HEALTH PERMIT/SERVIE�S Any MINOR violations noted in the"Notice to Comply" in the attached inspection report must e corrected within 30 days of receipt of this inspection. This certification form must be submitted to the Environmental Health Department (FHD)address at the top of this form within 35 days of receipt of the inspection report. All corrections to other violations noted in the attached Inspection Report(TR)or Continuation Form, or disputes to any violations, are to be submitted using this certification and-returned to EHD within 60 days unless otherwise specified in the IR. For this certification t0 De Cuffs-/etc fne uperetaor oft he si± m„st irrlude: • A statement documenting wbat corrective actions were taken or will be taken for each violation. • Copies of sample results/man,ifests/training records/other appropriate paperwork, and/or photos verifying corrections • Operator's certification Inspection Date: C,0,w s Inspected By: i o Ks u� Facility Address:�ISO ? EPA ID#: I certify under penalty of law that: 1. 1 have corrected the violations specified in the inspection Report from tate above-mentioned inspection date- 2itted as roof of . I have personally examined the evelthelttxformation t be true,ng documentation accurate,and complete: FOR EACH VIOLATION and I belt photes papPxwozlc Statement 3. I am authorized to submit this certification on behalf of the Respondent. 4. 1 am aware that there are significant penalties for submitting false infomati.on, including the possibility of a fine and/or imprisonment for known violations. (HSC 25191) Name: • • Title: �E Signature; T� Date: b(la EHD 22-02-005 Rev 12,04