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SAN JOAQUIN COUNTY RECEIVED <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 600 E.Main St., Stockton,CA 95202-3029 <br /> Telephone:(209)468-3420 Fax.(209)468-3433 Web:www.sj og v.org/ehd JUL 0 7 2011 <br /> ENV <br /> PERMIT/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 35 days of receipt of the <br /> Inspection Report. <br /> All corrections to other violations noted in the attached Inspection Report 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 ' e associated with failing to comply by the above noted dates will be billed at <br /> the current hourly rate($105). <br /> For this certification to 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 certifi ation <br /> ( Ins . �i 3`3 <br /> Inspection Date: ;01 © � y <br /> FacilityAddress: nn Inspected B• El Yo r��A ID#: 0 L C) '(-" <br /> I certify under penalty of law that: <br /> 1. I have corrected die 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 fin and/or imprisonment for known violations. (HSC 2519 1) <br /> Name: Title: <br /> Signature: Date: <br /> EHD 22-02-005 Rev 10-0 <br />