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SAN JOAQUIN COUNTY <br /> ENVIRONMIiN M,HEALTH DEPARTMENT <br /> 000 E. Maid St.,Stockton,CA 95202-3029 <br /> Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.sigov.ore/eIld <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 35 days of receipt of the <br /> Inspection Report. <br /> All corrections to other violations noted in the attached Inspection Report 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 billed at <br /> the current hourly rate ($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 /> e Operator's certification <br /> Inspection Date: `�`�fit s 1 Inspected By: t-Ai0 f, ' -' No l U <br /> Facility Address: .1;".hi 0"JI),u) ' ', EPA ID#: CA1-0t.r0044 <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 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. 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 Eine and/or imprisonment for known violations. (HSC 2519 1) <br /> i , '"t�� t�(,, � I� ) Title: �` " � i �S tr ° f, t. I;)1 <br /> Name: , 1 �' tti. SS ( Y f 1 <br /> Signature: ,. �` > ,� ..: i Date: _ m_ <br /> EHI) 22-02-005 Rev 10-07 <br /> v00 CII uI,L217I1fia VOR.LNVN LT9C6VZ60Z XFd 90:ZT OTOZ/5T/60 <br />