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002454 <br /> FUDIECENE'D <br /> SAN JOAQUIN COUNTY NOV 1 4 2008 <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 600 East Main Street, Stockton, CA 95202-3029 �:NVIRONMENT HEALTH <br /> Tele ',ona:(209)468-3420 Fax:(209)468-3433 Web:www.sigov.orci/ePORNIIT/SERVICES <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 vio ations 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 tirr a associated with failing to comply by the above noted dates will be <br /> billed at the cur ent 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, and/or photos <br /> verifying corrections <br /> • <br /> Operator's certification <br /> Inspection Date: Inspected By.- <br /> Facility Address: t-ti-A EPA ID#:k-j�66z4 5c75 SC) <br /> I certify under penalty of law that: <br /> 1. 1 have corrected tf a violations specified in the Inspection Report from the above-mentioned <br /> inspection date. <br /> LIGVC pCiSUlallyexamined the following dn umentat:ion Su biiiit!ed as proof of vC7n11i.unce 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 th re are significant penalties for submitting false information, including the <br /> possibility of a fine and/or imprisonment for known violations. (HSC 25191) <br /> Name ��E� �"� S Title: <br /> Signature- _ i� 2 Date- <br /> EHD <br /> ateEHD 22-02-005 Rev 08108 <br />