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05/94/2005 22:54 FAX 001 _ <br /> ` .. SAN J"QUMq COUNTY -. <br /> . V(kdVMENTAL14EALTRDEPARTMENT _ . <br /> 304 Eas�W eb�Avemc.3"F100r,Stockton,CA 95202-2708 <br /> Telepbendt(208)468-3420 Fax, (209)468-3433 WAb:iLln ov o AY —5 AH 2: O4 <br /> .:0 fil ::OUNTY <br /> E1jV'1130HK WTAL <br /> RETURN TO COMPLIANCE CERTIFICAiTJ4DEP: Rr,tENr <br /> Any MAVDR violations noted in the"Notice to Comply"in the attached inspection report mtrstt be <br /> ted witt++n 30 days of receipt of this inspection• This certification form must be submitted to the <br /> Environmental Health Departments(IIID)I address at the top of this form within 35 days of rec ipt 01 00 <br /> inspection report- <br /> All c ections then violations noted in the attached Inspection Report(IR)ar Continuation Form,or <br /> disputes to any violations,are to be submitted using this certification and returned to EHD witi"II 60 dM <br /> unless otherwise specified in the IF- <br /> P or this certification to be complete the operator of the site most include: <br /> . A statement documenting what corrective actions were taken or will be taken for each vj,ulation <br /> g <br /> Copies of sample results/marri£ests/trainin <br /> records/other appropriate paperwork, r photos <br /> verifying corrections <br /> Operator's certification <br /> bl;1�NiF ' <br /> Inspection Date: `� _� Inspected By: ' <br /> �L O1x.DQ?Y/V3 <br /> Faculty Address: 1 UG // jl %>1✓y �'� 4l � EPA ID#. r'�` <br /> I certify under penalty of la that- <br /> 1. I have corrected the violations specified in the Inspection Report from the above-m tiaaed <br /> inspection date- <br /> ineci the <br /> tafion <br /> f eD <br /> z. FACH VIOLATION and I believe <br /> the inforxnawing �oxni be true,aaccuratepandfocaa+pl P eFOR <br /> photos _paperwork Statement <br /> 3. 1 am authorized to submit this certification on behalf of the Respondent <br /> 4. 1 am aware that there are significant penalties for submitting false information unci the <br /> possibility of a fine and/or imprisonment for known violations. (HSC 25191) <br /> Name: C/u" Title_ <br /> Signature: Date: S•v> <br /> F111D 22-02-005 kev 12-04 T <br /> r0 39vd 600-Td H1JId EEb889b60Z 8"'T 9992/58/59 <br />