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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 600 East Main Street, Stockton, CA 95202-3029 <br /> Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.sjgov.or_ /q ehd <br /> I EC�I �l�1�D <br /> RETURN TO COMPLIANCE CERTIFICATION JAN 1 4 2010 <br /> ENVIRONMENT HEALTH <br /> Any MINOR violations noted in the"Notice to Comply" in the attached Inspection Report m` 'IIISERVICES <br /> corrected within 30 days of receipt of this inspection. This certification form must be submi to o the <br /> Environmental Health Department(EHD)address at the top of this form within 30 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 this certification and returned to EHD within 30 days <br /> unless otherwise specified in the Inspection Report. <br /> Note: All EHD staff time associated with failing to comply by the above noted dates will be <br /> billed at the current hourly rate of$105 (beginning 8/1/09 the hourly rate will be$115). <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 Date: / /' Inspected By: 4A6 ReTT tlAf 31< <br /> Facility Address: A1+4Me1Z LA , EPA ID#:<_AL_-Pcc b7xA o <br /> I certify under penalty of law that: <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 I/' Paperwork '� Statement <br /> 3- 1 am authorized to submit this certification on behalf of the Respondent. <br /> 4. 1 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 25191) <br /> Name: 991 e ��l U Title: 1'1-4N Z' �>7() <br /> Signature: '' Date: - G� <br /> EHD 22-02-005 Rev 06/09 <br />