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SAN JOAQUIN COUNTY <br /> ENvIRONMENTAL HEALTH DEPARTMENT <br /> 600 E.Main St., Stockton,CA 95202-3029 <br /> Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.s'gov.orWehd <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 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-9 AJ11 _ staff time associated .e ith f tiling to comply by the above noted dates wiH he bffled :' <br /> the cur rent hourly rate "S 1051. <br /> For $htS certification 1C�i1013 i0 �1C COI7IP]e1C the onerator of the site must inrl„ ie- <br /> Q <br /> Copies of sample results/m.= +' <br /> verifying corrections <br /> ao Ciperator7s ceriiication <br /> Inspection "Date: O "1A,�� Inspected By: <br /> Facility Address: ��� � � l-.N • U1 EPA TD#: <br /> I certify under penalty of law that: A- l 310 1 9j[ f Dmec_Tej O N Slfi�. <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. I am authorized to submit this certification on behalf of the Res onr1G� <br /> �i rte „ r, , <br /> .� �`n <br /> 4. I am aware that there are significant penalties for submitting falde I at. 1 t <br /> possibility of a fine and/or imprisonment for known violations. (HSC 2519 1) <br /> 0 T 2 0 2011 <br /> Name: ��� '�P(^ ��� sAN on:; r cowry <br /> � C Title: <br /> Signature: Date: O <br />