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• SAN JOAQUIN COUNTY • <br /> ENviRoNmENTAL HEALTH DEPARTMENT �C/'��I"r <br /> �® <br /> 600 East Main Street,Stockton,CA 95202-3029 Gv V <br /> Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.sj og v.org/chd <br /> JAN 11 2011 <br /> eONMENTAL RETURN TO COMPLIANCE CERTIFICATION PERMIT/SERVICE HMT" <br /> L <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 /> Allcorrectionsto other violations noted in the attached Inspection Report(IR)or Continuation Form,or <br /> disputes to any vro ahons,are to <br /> sub mitted using this certi&cation and returned to EHD within 30 day <br /> s <br /> unless otherwtse specified in the Inspection Report. <br /> Note: All EHD staff time associated with fag to comply by the above noted dates will be billed at <br /> the current hourly rate($122). <br /> For this Certlficatlon t0 be COm�lete the operator of the site mast include: <br /> • A statement documentingg what conechve actions were taken or will betaken for each violation <br /> • Copies of sample results/manifests/ttaining records/other appropriate paperwork and/or photos <br /> venfying corrections <br /> • Operator's certification <br /> Inspection Date: January 4, 2011 Inspected By: Garrett Backus <br /> Facility Address: 4715 N West Lane EPA ID#: CAL000182646 <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 X 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: Title: Nyc-y,C�W <br /> Signature: Date: ( Olt <br /> E14D 22-02-005 Rev 08/10 <br />