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FROM : BEOCON3696 • FAX NO. : 2098328815 •Feb. 16 2006 03:49PM P4 <br /> SAN-JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 304 East weber Avcnue,aro Floor,Stockton,CA 95202-2708 <br /> Telephone:(209)468-3420 For.,(209)468.3433 Web:www.sjgov.org/eh <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: t< o Inspected By: <br /> Facility Address: 1S3 E 1 I'Ll ST. eq& EPA ID#: eA L oot eg3eS <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. lam 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: JANPY fr<uW Title#gwToNg 4i�A✓r""&tyT'4 <br /> SignatureaCawvt^ �jo�dlrtuST <br /> Date: <br /> EHD 22-02-005 Rev 12-04 <br />