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SAN JOAQUIN COUNTY \� <br /> , NYIBONML�ITALHEALTH DEPARTMENT MAY 2 5 2007 <br /> 3"Floor,Stockton,CA 95202-2708 <br /> Telephone: (209)468-3420 Far:(209)468-3433 Web:www.s' ov.6 WNMENT HEALTH <br /> ERMIT/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 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 60 days <br /> unless otherwise specified in the IR. <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: VAM)l 07 Inspected By: X/I AIA/Oa <br /> Facility Address:_ 76412& �4L/y . EPAID#: CAI, OCZ2-7 ,7FOO <br /> I certify under penalty of 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 Paperwork Statement <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 imprisonment for known violations. (HSC 25191) <br /> Name: Wao�/ lze�"ad Title: I Af <br /> Signatur : Date: T Z$4-07 <br /> F,HD 22-02-005 Rev 12-04 <br />