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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 600 East Main Street,Stockton,CA 95202-3029 <br /> Tel hone:(209)468-3420 Fax:(209)468-3433 Web:www.sixov.or <br /> RETURN TO COMPLIANCE CERTIFICATION <br /> Any MINOR violations r oted in the"Notice to Comply" in the attached Inspection Report must be <br /> corrected within 30 days f 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 v olations 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 specifie 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 $125). <br /> For this certlflca ion 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 certifi ation <br /> Inspection Date: August 31 , 2011 Inspected By: Garrett Backus <br /> Facility Address: 2412 0 E Eight Mile Road EPA IM:CA J_DO0367925 <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. 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: l Imo✓ U Title: �I QD <br /> Signator Date: <br /> EHD 22-02-005 Rev 08/11 `' <br /> _L . . L <br /> SEF 2 8 2011 <br /> ,;AN JUMIU;d QO"Iy <br /> ENVRQNMEN T AL <br /> HEALTH DEPARTMEN1 <br />