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OS/22/2012 10:09 2093344684 #4220 P.002 /002 <br /> .002454 <br /> SA14 JOAQUIN GOUNTY <br /> FI AKC?NME ..HEALTH' bEPAarMEW <br /> 600.Eak Main et,Stockton,CA 95202-302.9 <br /> Tafep�unes(209)468-3420 r(209)468-3433 Web:www.siqqv oN&hd <br /> RETURN t0 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 r.ec:eipt of this inspection. This certification form must be submitted to the <br /> Environmental Health Department(EHD)address at the top of this form within 30 days of receipt of the <br /> Inspection Report. i <br /> All corrections to other violations rioted in the shed Inspection Report(IR)or Continuation Form, or <br /> disputes to,any violatiaft, are to be Aubmittedusing this cerfil"ication and returned to EHD AOM 30 days <br /> unless otherwise specified in the ImpactionR�port. <br /> Note: All EHD staff time associated with wiling to comply by the above noted dates will be <br /> billed at the current hourly mate. l <br /> F <br /> For this certification to be complete the operator of the site must include: 1 <br /> • .A statement documenting what corrective actions.were taken or wil be taken for each violation l <br /> • Copies of sample results/manifests/training records/other appropriate paperwork, andlor photos <br /> verifying corrections <br /> • Operators certification <br /> Inspection Date: " d ` -- Inspected By: I <br /> Facility Address: ''- _ EPA ID#:_ <br /> - ! certify undernal <br /> pe ty of law that: <br /> s <br /> 1. 1 have corrected the violations speciflea in the Inspection Report from the above-meat oned <br /> inspection date. <br /> 2. 1 have personally examined the following documentation submitted as proof of compliance FOR <br /> EACH VIOLATION and I believe the:iriforrnatiorr to be true, accurate,and complete: <br /> Photos Paperwork /Statement <br /> 3. 1 am authorized to submit this certifff"tion on behalf of the Respondent. , <br /> f <br /> 4 1 am aware that there are significatYt41A <br /> nalties for submitting false information, including the <br /> possibility a a and/or impriso. far known violations. (HSC 25191) <br /> Name: 0 Title: c.• <br /> Signor A <br /> Date- <br /> 4 <br /> i <br /> EHD 22--02-OU Rft MOB <br /> I <br />