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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL AL DEPARTMENT <br /> 600 East Main Street,Stockton,CA 95202-3029 0 C T 0 7 2011 <br /> Telephone:(209)465-3420 :(209)465-3433 Web:m_._sj ov.or eh <br /> 1/f <br /> IT/SERVICES&.1' <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(EH )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 spection Report(IR)or Continuation Form,or <br /> disputes to any violations,are to be submitted ing this certification and returned to EHD within 30 days <br /> less 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 ourly rate($122). <br /> F this certification to be comp1 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 ate: // Inspected y: <br /> Facility Address: �?p ef��/ � �� e��e EPA I :I I certify under penalty of law at: <br /> 1. 1 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,accurate, and complete: <br /> Photos Paperwork Statement <br /> . 1 am authorized to submit this certification on behalf of the Respondent. <br /> . 1 am aware that there are significant penalties for submitting false information, including the <br /> possibility of a fineand/or imprisonment for known violations. (HSC 25191) <br /> Name: AA4 LJo 'Title: :5 _7U vd56P <br /> Signature: ate: Df P <br /> E D 22- 2-005 Rev 08/10 <br />