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SAN JOAQUIN COUNTY 49 <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 600 East Main Street Stockton, CA 95202-3029 <br /> Telephone: (209)468-3420 Fax:(209)468-3433 Web:www.sigov.onglehd <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. <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. <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 of$105 (beginning 811f09 the hourly rate will be$115). <br /> For this certification to be complete the -site must in,d <br /> e: <br /> * A statement documenting what corrective actions were t h for pa I 'on <br /> ir 9V( <br /> * Copies of sample results/manifests/training records/other ap)Mpropria e otos <br /> p <br /> verifying corrections NOV 12 Z009 <br /> • Operator's certification <br /> JU�WILAN CQUIM <br /> EW;'N%M*E1NTA <br /> Inspection Date: oInspected A 6^ <br /> s <br /> Facility Address: k�.mok EPA ID#: CALC-00 2-05� 3 <br /> �6,\ , 4c-,k qs� <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 information, including the <br /> possibility of a fine and/or imprisonment for known violations. (HSC 25191) <br /> Name: Title: <br /> Signature: Date: k <br /> EHD 22-02-005 Rev 06/09 <br /> C966-W7-60Z 8Jl9AI!s no-1 BKO1, 60 ZI, AON <br />