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FROM MARIGOLDSHELL PHONE NO. : 209 952 4862 Oct. 19 2006 01:52PM P2 <br /> SAN JOAQUIN COUN-rY o- ' <br /> ENVIRONMENTAL HEALTH DEPARTMFNT <br /> 304 Fast Weber Avenue.3id Floor, Stoekton,CA 95202-2708 <br /> TWephune: (20)468-3420 Fax:(209)468 433 Web:www.cj4ov ,e d <br /> RETURN TO COMPLIANCE CERTIFICATION <br /> Any MITTOR violations ;toted in the "Notice to Comply" in the attached inspection report trust be <br /> corrected within 30 days of receipt of this inspection. This certification form must be submitted to the <br /> Environmental 1-lealth Department(EHD)•address at the top of this form within 35 days of receipt of the <br /> inspection report. <br /> All corrections to other vi-olations 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 60 days <br /> unless otherwise specified in the IR. <br /> cr <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 /> • Copics of sample results/manifests/training records/other appropriate paperwork, and/or photos <br /> verifying corrections <br /> • Operator's certification <br /> Inspection Date: � � /f — O � Inspected <br /> EFacility Address:--�57oG7cA.I, 6A. V�V O7 EPA ID#: <br /> I <br /> I certify under penalty of law that: { <br /> { I <br /> 1. I have corrected the violations specified in the Inspection Report from the above-mentioned <br /> inspection date. f <br /> 2. I have personally examined the following documentation submitted as proof of compliance FOR i <br /> EACH VIOLATION and I believe the i n formation to be true, accurate, and complete: (� <br /> _Photos V` Paperwork _ Statement <br /> 1 I 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, including the <br /> possibility of a fine and/or imprisonment for known violations. (HSC 2519 1) <br /> I <br /> fName: U,(�C�� ;.�-r'-�t�C 1WIV Title: ��1�t1iClE <br /> Signature 4 :, cz c �,t v Date: <br /> EH D 22-02-005 Rev 12-04 <br />