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Apr 08 14 01:20p ARP 12ng8352297 p.1 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT RECEIVI: <br /> 1868 East Hazelton Avenue, Stockton. California 95X5-6232 D <br /> Tlephone:(299)468-3420 Fax:(209)468-3433 Web:www.sl4ov-.orq[ehd <br /> 08 ['Q1 <br /> RETURN TO COMPLIANCE CERTIFICAT10101VIRONMENTALAH')EPAMT <br /> T <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. HSC 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 EFID 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 tl,e site must include: <br /> • A statement documenting what corrective actions were taken or will be taken for each violation <br /> • Copies of sample results/manifestsltraining recordslother appropriate paperwork, and/or photos <br /> verifying corrections <br /> • Operator's certification <br /> Inspection Date: G�_Ch 2 � T(-)Ib{ Inspected By: 1W-)YTt���,r <br /> Facility Address: Qt, +,�5­ EPA ID#: <br /> I certify under penalty of law that: <br /> 1. I have corrected the violations specified in the :r.spection 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, occur te, 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 information, including the <br /> possibility of a fine andlor imprisonment for known violations. (HSC 25191) <br /> Name:_ P1 � -Title,- <br /> Signature: <br /> itle:Signature: Date: Z'i G/ <br /> EHD 22-02-005 Rev 04119,12 <br />