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• <br />SAN JOAQUIN CouN" ry <br />ENv[K0N,%1FhrrAt. HEALTH DEPARTMENT <br />660 East Main Street, Stocktaa, CA 45202.3029 <br />Telephone. (269) 4+68-3420 ,Pax; (209) 468-3433 Web. wwwasieav_4xe/e)d <br />RETURN TO COMPLIANCM CERTIFICATION <br />Any =OR 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 ov=gfions to other violations noted in the attached Inspection Report (IR) or Continuation Form, or <br />disputes to airy violations, -are to be submitted using this a.�ifrcation and returned to EHD )�jt)u30 days <br />unless otherwise specified in the Inspection Report. <br />Note: All EFID staff time associated with failing to comply by the above noted dates will be billed at <br />the c=ent hourly rate (198). <br />For this certification t0 be COMPlete the operator of the site must include:. <br />• A statement documenting what c=ective actions Frere taken or will be taken for each violation <br />+ Copies of sample results/manifesta/training records/other appropriate paperwork, and/or photos <br />verifying corrections <br />a operatoes certification <br />Inspection Date: 2r`%/ �'/�y� - Inspected By: <br />C,,,5 Igo 5_1-1f7;_17 /ufi <br />Facility Address: 7-440 jl%I/e2k C",' EPA ID #: iYaR ��9z2�q <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- MAI)) AS D X 13r v /,,V {V I&/r.�l <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 Papenvork Statement <br />3. I am authorized to submit this certification on behalf of the Respondent. <br />4. 1 am aware that there are significant peual6es for submitting false information, including the <br />possibility of a fine and/or imprisomnont for known violations. (HSC 2519)) <br />Narne: +Jr1�J CJdc�f <br />Title: <br />Date: Z �� <br />6Z:Et 64-80-6002 <br />I/£ sd . W04 A3080 JO� wd££ 4:0 6002/6l/Bo panLaaaa <br />