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04/Z7/zull Y:: 1) YAX 4UN'W003'4,s.s OOL now •e•�� --- <br /> SAN JQAQVIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 600 E.Main St.,Stockton,CA 95202-3029 <br /> Telephone:(209)46$-3420 Fax:(209)468-3433 Web:wMv qjg(thd <br /> APR 2_8 _2011 -- <br /> RETURN TO COMPLIANCE CERTIFICATION",'G TALC <br /> HEALTH DEPARTMENT <br /> AnyIM NOR 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 pgnng boils to other yi tions noted in the attached Inspection Report 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 billed at <br /> the current hourly rate($122). <br /> For this certification to be complete the operator of the site must include: <br /> • A statement documenting what corrective actions were taken or will be taken for each violation <br /> • Copies of sample results/manifests/training records/other appropriate paperwork,and/or photos <br /> verifying corrections <br /> • Operator's certification <br /> Inspection Date: Inspected By: /U of.I <br /> Facility Address: ` S_ a PA ID##: 4 G o.3 5-6 SZ <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 subunit 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: ..3;A S t 1C H 17 Title: C) 60 N <br /> Signature: �"l`� Date: L/- Z 8 <br /> EHD 22-02.005 Rev 08/10 <br />