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01/29/2013 16:51 FAX 12094658060 BULKST0CKT0N@BULK—DTI.00 Z0003/0008 <br /> is <br /> 1 <br /> i.' <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1868 East Hazelton Avenue, Stockton, California 95205-6232 <br /> Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.s!goov.org/ehd <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 30 days of receipt of the <br /> Inspection Report, NSC 25404.1.2(c)(1) <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 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 t0 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, and/or photos <br /> verifying corrections <br /> p • Operator's certification <br /> F <br /> Inspection Date: r�`� l� Inspected By:Stacy Rivera <br /> Facility Address: 3d0 2 S . � © EPA ID#: Oq-1- 0002'74731 <br /> tY <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 /> o <br /> t Photos _Paperwork Statement <br /> 3. 1 am authorized to submit this certification on behalf of the Respondent. <br /> ( <br /> 4. 1 am aware that there are significant penalties for submitting false information, including the <br /> V4 possibility of a fine and/or imprisonment for known violations. (HSC 25191) <br /> Name: Lw�l't/ Title: �d --(rNoACe W&x+ ,C -� <br /> Signature: Date: <br /> EHD 22-02-005 Rev 04/19/12 <br />