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11/05/2010 15:09 2099316743 Paterloo Food Mart #0420 P.002/006 <br />SAN 30AQL` N COUNrY <br />ENVIRONINIENTAL REALTFI DEPARTMENT <br />600 East Main Street, Stockton, CA 95202-3029 <br />Telephone: (209) 468_3420 Fax: (209) 468-3433 Web: www.sjgov_org/phd <br />RETURN TO COMPLLA.NCE CERTMCATYON <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 35 clays of receipt of the <br />Inspection Report. <br />-AlFcorrections, to other violations noted in the attached Inspection Report (IR) or Continuation Form, or <br />disputes to an:y vin aA <br />tinnc YP te, mbmue <br />ltted inS thir ce txfiouiio. an rotumod to i7,I b wiLljiu j() /lays <br />unless otherwise specified in the .Inspection Report. <br />2`7o£�a .ki: inTT1) ....R :.... .._ i..a�al ..,ata 6 w comply oy mle avovc norca QAoea Twill bu JHW at <br />the current hourly rate ($122). <br />For this certificatian to be. rnmplete tha opa.. oftb. Bite moot inclndo. <br />.t...-......-.{..si wt�i oozroou�-c aQU012D »-oro ta.lcc:cx or vv --11 L.. La�i�,,11 lv1 ud;,11 ViUjULjoU <br />• Copies of sample results tem fests/ttaiiaing records/other appropriate paperwork, and/or photos <br />verifying corrections <br />• Operator's certification <br />Inspection Date: October 8, 2010 <br />Inspected By: Garrett Backus <br />f acility Address. 4315 Waterloo Road EPA fl": H? <br />I certifv usldLyr penalty of ln,u that• <br />1 f have <br />irLopo-tiou daL� . •�aas <br />2. 1 have ver ,onally cxgrnlnc-A t1, P. fntlnta �..}S .1.,. •a.aa ratatiora aulx+,; cr.v a .,. r«c o£ o£ c :,.. .. ... T`ll.r <br />EA( -:11 viULAIION and I believe the iLiftimalioLl to be true, accurate, and complete: <br />3. 1 am authorized to ClLhmit thrtC r-Prtifi-al;nn nn bohalf of tho <br />4- T xaii :xvure. th3T d-,eM arc siJ Mticant DciudLlu:s tilt :sithinittine fnlcr- i��Liarrns�lir�n innla.A;,.� tho <br />possibility of a fine and/or imprisonment for known vinlatinnc <br />Name: Titic: <br />Mgnanlre: pr,A,ra 1 ,,1.1t L, Data- <br />EHD 22-02-005 Rev 08/10 <br />