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07/27/2007 15:12 FAX 209 983 5305 CLASS IX #2 Z002 <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />304 East Weber Avenue, 3 Floor, Stockton, CA 95202-2708 <br />Tel 3phone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sj o� v.or <br />RETURN TO COMPLIANCE CERTIFICATION <br />Any MINOR, violations t toted 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 D. apartment (EHD) address at the top of this form within 35 days of receipt of the <br />inspection report. <br />All corrections to other N iolatiom noted in the attached Inspection Report (IR) or Continuation Form, or <br />disputes to any violation, :, are to be submitted using this certification and returned to EHD within 60 days <br />unless othenrise specific d in the 1R. <br />For this itiertlf ca Lion 1LO be complete the operator of the site must include: <br />• A statement docs mentin, what corrective actions were taken or will be taken for each violation <br />• Copies of sampl(: result&manifests/training records/other appropriate paperwork, and/or photos <br />verifying correct ons <br />• Operator's certif cation <br />Inspection 1Date: 4,0 _ Inspected By: % �N r <br />Facility Address: -5, EPA ID#: C /I qd' <br />I certify (.mder penall y of law that: <br />1. I have corrected i he violations specified in the Inspection Report from the above-mentioned <br />inspection date. <br />2. I have personally examined the following documentation submitted as proof of compliance FOR <br />EACH VIOLATi ON and I believe the information to be true, accurate, and complete: <br />Photos it Paperwork Statement <br />3. I am .authorized t) submi:: this certification on behalf of the Respondent_ <br />4. I am ,aware that t3 tere are significant penalties for submitting false information, including the <br />possibility of a f: ie and/or imprisonment for known violations. (HSC 2519 1) <br />Name:_ - � %h "tVCCry Title: %I/J2 <br />Si atu:G� /'i ,,� ,�, <br />�:� : Date: .-' <br />� , <br />