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10/19/2009 08:22 FAX 209 983 5305 CLASS IY #2 002 <br />SAN JOaZ4;iT 1 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.si-lov.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 />correct6d within 30 days,of receipt of this inspection. This certification form must be submitted to the <br />tiVirohrnehtsl Ho!slth Department (EHD) address at the top of this form within 30 d, s of receipt of the <br />Inspection Report. <br />All oarreetrc' to either violations noted in the attached Inspection Report (IR) or Continuation Form, or <br />-- , --� <br />disputes, to airy v'Ioldtions, 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 M-1he current hourly rate of $105 (beginning 8/1109 the hourly rote will be $115). <br />Forth-is,Cel-tlfication t0 be complete the operator of the site must include: <br />'® A`ist��terrfiil`docurnenting what corrective actions were taken or will be taken for each violation <br />G6gji6is of 148": iple results/manifests/training records/other appropriate paperwork., cind/or photos <br />verifying corrections <br />.. Operator' certification <br />i— .-1':,•:+r•�c, e;+.:c. i.w. y; rI .'i' my ::n'a. �+n::.e.n:vu'.,., .uwu. r�..a++..:in .:w �mm�._+i:��•c_�+'.:1,waa +ar.:::vrw,� .-<• ...�.�:.-.:.+.. �. ,:»:.�.. :i�i�7�i <br />, <br />y 0 - <br />��.�,-�, <br />74 <br />FacilkyAd <br />-' <br />mo <br />io <br />l certify under penalty of law that: _ _ _ _ _ _ _ -- -- _ _-.._.......:..-. ............. <br />-1; ' 6`cdreL-cted the violations specified in the Inspection Report from the a�have-mentioned <br />inspection date. <br />2 , I have personally examined the following documentation submitted as proof of compliance FOR <br />'.:0- E;ACHj1VI'OL.ATION and I believe the information to be true, accurate, and complete. <br />01 <br />Paperwork ^Statement <br />Photos 3< <br />IKL <br />3. 1 am authorized to submit this certification on behalf of the Respondent_ <br />avrgf6`that there are significant penalties for submitting false informa. ion, inCtuding the <br />possibility of a fine and/or imprisonment for known violations. (HSC 25191) <br />C D 1 Title' <br />Name �1 �, I�1 % 1"_',_ "�-- --W� : ���5�� �.. <br />. <br />-- --- <br />Ir <br />Sianatur : Date: �® % `��' /- — <br />EHD 22-02-005 Rev 06/09 <br />