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JUN-12-2888 09:16A FROM: TO:4683433 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 600 East Main Street,Stockton,CA 95202-3029 <br /> Telephone:(209)468-3420 Fac:(209)468-3433 Web:wmw,NigQy.org/ehd <br /> RETURN TO COMPLIANCE CERTIFICATION <br /> Any M—WOR violations noted in the"Notice to Comply"in the attached Inspection Report must be <br /> coEMctgd within 30 days of receipt of this inspection. This certification form must be submitted to the <br /> Environmental Health Department(END)address at the top of this form within 35 days of receipt of the <br /> Inspection Report. <br /> All correctigns tiLothcr violations noted in the attached Inspection Report(IR)ar 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 billed at <br /> the current hourly rate ($98). <br /> For this certification to be complete the operator of the Site must include: <br /> a A statement documenting what corrective actions were taken or will he taken for each violation <br /> • Copies of sample msults/manifests/training records/other appropriate paperwork, and/or photos <br /> verifying corrections <br /> a Operator's certification <br /> Inspection Date: �a a Inspected By: <br /> Facility Address: e;1,3o90 F I Ww ab EPA ID#: C4-L' dao 42 q 4 <br /> I certify under penalty of law that: <br /> 1. 1 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 k Statement <br /> 3. I 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: �o he, 4 VY\. L.w4 2 Title: \/,t-e <br /> Signature: Date: <br />