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209 832 4259 00 '9:51 a.m. 05-06-2010 2/2 <br /> SAN JOAQUIN 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.sigov.orct/ehd <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 30 days of receipt of the <br /> Inspection Report. <br /> All corrections 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 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 at the current hourly rate of$105 (beginning 8/1/09 the hourly rate will be $115). <br /> For this certification t0 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:_ Z3 ;� t ; Inspected By: <br /> Facility Address: ?eAe w EPA ID#: 07 A 0 11 8 if'73 71 3 <br /> If I certify under penalty of law that: <br /> _ i <br /> 1. 1 have corrected the violations specified in the Inspection Report from the above-mentioned <br /> inspection date. <br /> i <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. l am authorized to submit this certification on behalf of the Respondent. <br /> i <br /> 4. 1 am aware that there are significant penalties for submitting false information, including the <br /> j possibility of a fine and/or imprisonment for known violations. (HSC 25191) <br /> Name: de.GSe, r ,-a; Title: W k4 <br /> Signature: , . ,� .. , , date: '; <br /> --- tune - - -----------= ------ -- - t— _ —_ <br /> EHO 22-42-005 Rev 06/09 S" ' <br />