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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 600 East Main Street, Stockton,CA 95202-3029 <br /> Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.si og v.or /g ehd <br /> RETURN TO COMPLIANCE CERTIFICATION <br /> Any MINOR violations rioted in the "Notice to Comply" in the attached Inspection Report must be <br /> corrected within 30 days f 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 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 tinae associated with failing to comply by the above noted dates will be billed at <br /> the current hourly rate($122). <br /> For this certiflca ion to be complete the operator of the site must include: <br /> • A statement doct menting what corrective actions were taken or will be taken for each violation <br /> • Copies of sampl( results/manifests/training records/other appropriate paperwork, and/or photos <br /> verifying corrections <br /> • Operator's certi cation <br /> Inspection Date: Se,tember 29, 2010 Inspected By: Garrett Backus <br /> Facility Address: 1621 Brookside Road EPA ID#: CAL000040942 <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. I have personal, examined the following documentation submitted as proof of compliance FOR <br /> EACH VIOLAT ON and I believe the information to be true, accurate, and complete: <br /> Photos )C Paperwork Statement <br /> 3. lam authorized o submit this certification on behalf of the Respondent. <br /> 4. I 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: i,,) Title: 72— /�cC <br /> Signature: Date: <br /> EHD 22-02-005 Rev 08/110 <br />