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Mar -15-2007 02:46pm From- T-858 P.003/010 F-054 <br />6AN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />304 East Weber Avenue, 3`d ploon, Stockton, CA 95202-2708 <br />Telephone: (209) .468.3420 Fax. (209) 468-3433 Web. WIML <br />RETURN TO COMPLIANCE CERTIFICATION <br />Any ATLOR violations noted in the "Notice to Comply" in the attached inspecti,>n report must be <br />corrected with 30 da s of receipt of this inspection. This certification form must be submitted to the <br />Environmental Health Department (EHD) address at the top of this fo <br />inspection report rm within 35 days of receipt of the <br />All corrections to other violations noted in the attached Inspection Report (1R) or Continuation Form, rm, or <br />disputes to any violations, are to be submitted using this certification and returne;i to FI;IU within r da $ <br />unless otherwise specified in the IR. <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 pap,�rwork, and/pr photos <br />- verifying corrections <br />• Operator's certification <br />Inspection Date: �2 %200 -7 Inspected By: L 6n <br />Facility Address: d erL-T -ruc-lC z4ic4� FPA ID#:6INL DUD,�-70(p (/ <br />3G33 u K4e2 <br />I certify under penalty of law that: :5 74-K l -D n <br />1 _ I have corrected the violations specified in the Inspection Report frorn the .above-mentioned <br />inspection date.. <br />2. I have personally examined the following documentation submitted as pro of of compliance FOR <br />EACH VIOLATION and I believe the information to be true, accurate, an([ complete, <br />Photos Paperwork �- t tement <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 i) <br />Name:.--- <br />P` (Z //Cl vv--\ —Title-—12Z�,r r/ <br />a'k-t� I Date: <br />ERD 22-02-005 Rev ; 2-04 <br />