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• SAN JOAQUIN COUNTY • mcaVED <br /> ENVIRONMENTAL HEALTH DEPARTMENT v <br /> 600 East Main Street, Stockton, CA 95202-3029 RR 2 7 2010 <br /> Telephone:(209)468-3420 Fax:(2 09) 468-3433 Web:www.s' ov.or 9& <br /> ENVIROWENT HEALTH <br /> FERMITtSERVIeES <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 30 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 30 days <br /> unless otherwise specified in the Inspection Report. <br /> Note: All EHD staff time associated with failing to comply by the above noted dates will be <br /> billed at the current hourly rate. <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 /> InspectionDate: �� �� Inspected By: c !^ <br /> i <br /> Facility Address: /7/6a Hati(v!- yid EPA ID#: 64 <br /> 1-.a�tfit-off � G, 9's3s� <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. 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 �aperworky Statement <br /> ,tp <br /> 3. .,t 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: l.)E tj &00r Title: DIVISroa Mfi✓Rt-r"-6-- <br /> Signature: Date: y .'r& /3010 <br /> EHD 22-02005 Rev 10109 <br />