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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTME <br /> 600 East Main Street, Stockton, CA 95202-3029 D <br /> Telephone: (209)468-3420 Fax: (209)468-3433 Web:www.siQoy.orq/eh L <br /> s�M�, <br /> VIRONMENTh <br /> RETURN TO COMPLIANifE CERTIFICATIO�oERAjIT/SERVHE Lr,� <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$11'05 (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: (21 t (Z-00r, Inspected By: T4 Vic k� <br /> Facility Address: 1400 f. kA[A,"o V_oA4EPA [D#:—(? A-E) l l 5n°1 Z02S <br /> 1-certify under penalty of-law that: _ _.- <br /> 1. I have corrected the violations specified in the Inspection Report from the above-mentioned <br /> inspection date. <br /> 2. I have personally examined the following documentation submitted as proof of compliance FOR <br /> EACH VIOLATION and I Zieve the inform tion to be true, accurate, and complete: <br /> Photos Paperwork Statement <br /> 3. 1 am authorized to submit.this certification on behalf of the Respondent. <br /> 4. 1 am awa that there are significant penalties for submitting false information, including the <br /> possibilit of a fine and/or imprisonment for known violations. (HSC 25191)L - <br /> Name: ur Title: MAtit) <br /> cl Signature: Date: �Z I f l C) 9 `// <br /> EHD 22-02-005 Rev 06/09 <br />