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08/06/2008 09:14 FAX 209 983 5305 CLASS IY #2 Z002/003 <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />600 East Main Street, Stockton, CA 95202-3029 <br />Telephone: (209) 468-3420 Fax: (2-09) 468-3433 Web: www.siQov.orWehd <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 35 days of receipt of the <br />Inspection Report. <br />All correcti6ns•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 &ith_i_n_ 30 days <br />unless otherwise specified in the Inspection Report. <br />Note: AWEHlYstaff, time associated with failing to comply by the above noted dates will be billed at <br />_..the current hourly rafe ($98).- ___ - _ <br />_... - - - _ ... - __.. - - ---............ <br />For this'.certification t0 be complete the operator of the site must include: <br />'A st:titetn<iit documenting what corrective actions were taken or will be taken for each violation <br />Coples of �sdinple results/manifests/training records/other, appropriate. paperwork, anti/or,photos. <br />. ,venfytaig corrections <br />Operator's certification <br />ItIsl ection Dater Ze � Inspected By:�1�l <br />Facility Address:_ ! d 5, d XPA ID#: P)_�D. <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 pe'sonally 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. I am authorized to submit this certification on behalf of the Respondent. <br />4. 1 ani 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: <br />Si <br />F.T411 ??_00-005 R Pv 11 A17 <br />I�['tl L IJP Title: <br />Date: <br />—.6-0 <br />