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SAN JOAQUIN COUNTY h ,C <br />EIVED <br />ENVIRONMENTAL HEALTH DEPARTMENT e <br />600 East Main Street, Stockton, CA 95202-3029 <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sj¢ov.org/chd 2011 <br />VIRONMENTAL HEALTH <br />RETURN TO COMPLIANCE CERTIFICATION PERMIT/SERVICES <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 (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 time associated with failing to comply by the above noted dates will be billed at <br />the current hourly rate ($122). <br />For this certification cation 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 />• Operator's certification <br />Inspection Date: f'a b. 9 2 Inspected By: <br />Facility Address: 5 Z 1 W «l��f EPA ID#: C t'n <br />[ L D O O 821 g g Z <br />I certify under penalty of law that: <br />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. 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 2519 1) <br />Name:j�?04-11 Title: Fny1,10AMer,+'+ 5 e j 1 <br />Q. <br />Signature: w' O"'o— Date: .3 /1 I 011 <br />EHD 22-02-005 Rev 08/10 <br />