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FROM LAKEWOOD PHONE NO. 209 3336306 Mar. 07 2007 10:50AM P2 <br /> SAN JOAQIUIN COUNTY <br /> ENVIRONMENTAL HEAI.,TH DEPAR'T'MENT <br /> 304 East Weber Avenue,3d Floor,Stockton,CA 95202-2708 <br /> relephone:(209)468-3420,;Fax:(209)468-3433 Web:www,sieov oor chd <br /> RETURNTO 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(IR)or Continuation Form,or <br /> disputes to any violations, are to be submitted using thi <br /> unless otherwise specified in the IR. s eerti.ficatian and returned to I✓I:ID within 60 days <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 /> • Operator's certification <br /> Inspection bate: Inspected Jay: <br /> Facility Address: g� C �/ EPA ID#: <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. 1 have personally examined the following documentation submitted as proof of compliance FOR <br /> E.A.CH VIOLATION and I believe the information to be true,accurate, and complete: <br /> Photos , 'J 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 me and/or imprisonmentfor known violations. (HSC 25191) <br /> I /11a <br /> fb(,Ji, -Name: A111, n- 'Title: <br /> Signature: till Date: rd A Fi` <br /> F-H D 22-02-005 Rev 12^04 <br />