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SAN JOAQUIN COUNTY db <br /> I ' ENVIRONMENTAL HEALTH DEPARTMENT <br /> U� S� 304 East Weber Avenue,3rd Floor,Stockton,CA 95202-2708 n�A <br /> Telephone:(209)468-3420 Fax:(209)468-3433 Web: www.s12ov.ojj (V`EIV ED <br /> b <br /> 0 2013 <br /> RETURN TO COMPLIANCE CERTIFICMWQjNT� <br /> PERMIT/SEFMCES H <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: �Wa X, LO 3 Inspected By: 'jkQg� 12.iyeC12_ <br /> Facility Address: q-4q f- rn a r�I(1- EPA ID#: <br /> 11n e4v p �j r. <br /> I certify under penalty of law that43 <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 __Statement <br /> 3. I am authorized to submit this certification on behalf of the Respondent. <br /> 4. I 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: M �U �,q 11,1 4ca CU-)-W41 <br /> Signature: Date: D <br /> EHD 22-02-005 Rev 12-04 <br />