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03/30/2006 13: 32 21394683433 EHD PAGE 04 <br /> SAN JOAQUINCot;NTY RRC EKED <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 304 Fast weber Avenue,3'd Floor, Stockton,CA 95202.2708 APR 1 S 2006 <br /> Telephone:(209)468-3420 Fax.(209)468.3433 Web:www.siaov.or�lthd <br /> ENVIRONMENT HEALTH <br /> RETURN TO COMPLIANCE CERTIFICATION <br /> Any M11N violations noted in the "Notice to Comply" in the attached inspection report.roust 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 dans <br /> unless otherwise specified in the IR. <br /> For this certification to 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/trainiug records/other appropriate paperwork, andlor photos <br /> verifying corrections <br /> • Operator's certification <br /> ? Inspection Dater -a(,� .0�o Inspected By: LQ r -S <br /> Facility Address:c;603 1.e1Pup. _ EPA TD#:C-RR 0Q ) 14l!3 <br /> I certify under penalty of law that: <br /> i <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 VIOLA'1710N and I believe the information to be true, accurate, and complete: <br /> Photos_____Paperwork__Statement <br /> 3. I am authorized to submit this certification on behalf of the Respondent. i <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 /> j 1 <br /> Name tc�c, rc� +—Title , r �ahypllonee OA <br /> �- � V <br /> Si attire: �JI � Date: <br /> EHD 22-02-005 Rev 12-04 <br />