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SAN JOAQUIN COUNTY W <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 600 E.Main St.,Stockton,CA 95202-3029 APR ® 6 2012 <br /> Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.sjgov.org/ehd <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 f <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 oiherwise specified in the Inspection Report. <br /> ;dote: All EHD staff time associated with failing to comply by the above noted dates will be billed at <br /> the current hourly rate ($120. <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/trainin records/other appropriate paperwork, and/or photos <br /> verifying corrections CC n _,)__Z) <br /> • Operator's certification a 1� <br /> Inspection Date: cj Vv�n�1��� �Ot� Inspected By: I _L-o-.\ <br /> Facility Address: C r) 0 4�'A EPA ID#: t 9 Ll 1-7/ <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. 1 have personally examined the following documentation submitted as proof of compliance FOR <br /> EACH VIOLATION and I believe the information to be true, ac <br /> curate, and complete: <br /> Photos Paperwork <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 fine and/or imprisonment for known violations. (HSC 25191) <br /> o - r <br /> Name: L,�r) oA �� (`,\�, ( IV\ u'iNCO Title: Ow�P/� <br /> Signature: _.. Date: <br /> EHD 22-02-00 ev 08/10 <br />