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SAN JOAQUIN COUNTY <br /> E <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 6()0 East Main Street, Stockton, CA 95202-3029 <br /> Telephone.,(209) 468-3420 Fax. (209)468-3433 Web:www.sjoov.ora/eh P 2 5 2009 <br /> PEALi` <br /> CE,�ART,46\7 <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: AD EHD staff time associated with failing to comply by the above noted dates will be <br /> billed at the current hourly rate ($105). <br /> For this certification to 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: Inspected By: RAe2l W0 �5 <br /> Facility <br /> Address: 1&7o EPA ID#: 12,L( n6o 1403 <br /> la <br /> &L-ta— 0_4- <br /> I 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. 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. 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, including the <br /> possibility of a fine and/or imprisonment for known violations. (HSC 25191) <br /> Name:_ Title:— Alla <br /> Signature: Date: <br /> EHID 22-02-005 Rev 08fi08 <br /> I, d 6CI,6ZC660Z S32c2Oi O-lSVd d4l,:C0 60 9Z deS <br />