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07/14/2010 13:13 9164431276 RETAIL PAGE 01101 <br /> 102454 <br /> SAN JOAQUIN COUN-rY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 600 East Main Street, Stockton, CA 95202-3029 <br /> Telep'!one:(209)468-3420 Fax:(209)468-3433 Web:www.sjaov.o to d <br /> RETURN TO COMPLIANCE CERTIFICATION <br /> Any MINOR violations noted in the "Notice to Comply" in the attached Inspection Report must be <br /> corrected wi#hin 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 correC#ions to other violatigns rested in the attached Inspection Report OR) 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. <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, andlor photos <br /> verifying corrections <br /> . <br /> Operators certification <br /> Inspection Date: ► : ,v Inspected By: <br /> Facility Address:_( —L �� EPA ID#: <br /> I certify under penalty of law that: <br /> 1, 1 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 01� �Paperwo1�c 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: <br /> � Title,.— <br /> Signature: <br /> itle:Signature_ Bate- -7I1Li, <br /> EHD 22.02-008 Rey 08/08 <br />