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08113/2009 04: 13 2098873408 KAREN ARNAIZ PAGE 01/0G <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 600 East Main street,Stockton,CA 95202-3029 <br /> Telephone:(209)468-3420 Fax:(209)468-3433 Web:WwW inov.omg/ohd <br /> RETURN TO COMPLIANCE CERTIFICATION <br /> Any MINOR violations noted in the'Notice to Comply' in the attached Inspection Report must be <br /> « cted Within 30 d 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. HSC 25404.1.2(c)(1) <br /> All correction to otherVkAations 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, HSC 25185(c)(3) <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 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/training records/other appropriate paperwork, aril/or photos <br /> verifying corrections <br /> • Operator's certification <br /> Inspection Dater)ce I E ( Inspected By:Staey Riyera <br /> Facility Address: EPA lD#: <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_ 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 _Paperwork Statement <br /> 3. 1 am authorized to submit this certification on behalf of the Respondent. <br /> 4. 1 am aware that there are significant penalties for submitting false intonation, including the <br /> possibility of a tine and/or imprisonment for known violations. (HSC 25191) <br /> Name: Title: 0W n &r <br /> Signature: Date: 17 .2 3- f <br /> EHD 22-02-005 Rev 09/11 <br />