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SA.' JOAQULN COUNTY <br /> EPNI ROMMMAL&ALTH DEPARTMENT <br /> 600 B.Maiu$t,Stockton,CA 96202-30.29 <br /> Telephomt, (209)468-:3420.Fax:(209)458-3433 Web.,www.sigov-orQ/e id <br /> RETURN TO COMPLIANCE CERTIFICATION <br /> Any AOR violations noted in the"Notice to Corrnply"i the attached Inspeotiarn Report must be <br /> �Qrrectod withim.3.0 days of receipt of this inspectiou. This certification form must be submittttod to the <br /> Envirotmtental.Health Department(EHI))address at the top of this form within 35 days of receipt of the <br /> Inspection Report. <br /> All:corned ma to othat violations noted in the attached Inspection.Report or Continuation Form,or <br /> disputes to any violations, are to be submitted using this certification and remmed to EHD y6thin 30 dates <br /> unless otherwise specified in the Inspection Report- <br /> Note: All <br /> eport_Note: .All.EHD start time associated with i'aiW*to comply by the above mated dates wW be billed at <br /> the current hourly rate($122). <br /> For this certificat16n to be CoMplete the operator of the site must include: <br /> • A statement ilmtmenting what corrective actions were taken or will be taken for each violation. <br /> • Copies of sample results/manifests/training records/ether appropriate paperwork, and/or photos <br /> verifying catrecti,ons <br /> • operatWs certification <br /> Inspection Date: M&,Q C k 3 0 -2 012- Inspected By: In, /V r4!DL1 <br /> 1loo .5. MA04 ST. <br /> Facility Ad&ess;_fyARN_7-cc A c X533-4 EPA.M CAA 6A4 000 35-6 9 <br /> I certify under penalty of law that: <br /> 1. I have r:orrectW the violations spe-ifted in the Inspection Report facrcx,,tlae above-rnentioined <br /> inspection data. <br /> 2. t have personally examined the following documentation submitted as proof of compliance FOR <br /> EACH VIOLATl:ON and I believe the information to be true, accurate, and oomplete: � <br /> Photos,_Paperwork ._Stalemient <br /> 3. I am authorized to submit this cettiftcation on behalf of the Respondertat_ <br /> 4. I am aware that there are significant penalties For submitting false iufomukon,including the <br /> possibility of a fine and/or imprisomnent for known violations. (HSC 25191) <br /> l <br /> Naze: j p45 Big C HA D D A Title: PA R rNER <br /> Signature: Date: 1C—6-12 <br /> RHD 22-02-005 Rev 08/10 <br /> .. ..... .... .... �lu�cf u �nbpu� ue .. ....JNHl� ll..7l�37 4 Erni, <br />