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Oct 25 05 10: 16a LN Facilities Management (2 ) 339-7672 p. 2 <br /> SAKI JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 304 East Weber Avenue,3`d Floor,Stockton,CA 95202-2708 <br /> Telephone:(209)468-3420 Fax:(209)46$-3433 Web:www.sjgov.ore./ehd <br /> RETURN TO COMPLIANCE CERTIFICATION <br /> AnyMINOR violations noted in the"Notice to CotTiply"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` his c rtiiication and returned to EHD within 60 days <br /> unless otherwise specified in the IR. <br /> For $ 115 certification t0 be C®IYI?If?tt the operator of the site must include: <br /> • A statement documenting what corrective atrQns were taken or will be taken for each violation <br /> + Copies of sample results/manifests/training ecar�i,/other appropriate paperwork,and/or photos <br /> verifying corrections <br /> « Operator's certification <br /> Inspection Date: /0-aInspected By: 4LIRI I—ac-C,, C <br /> Facility Address: q? .S,alma T,4 I8f EPA ID#: N L 0(n e)0 q3 019 <br /> 5,7w <br /> I certify under penalty of law that: <br /> I. I have corrected the violations specified ip lie Inspection Report from the above-mentioned <br /> inspection date. <br /> 2. I have personally examined the fallowing docuin nation submitted as proof of compliance FOR <br /> EACH VIOLATION and I believe the W$"47 Vii)to be true, accurate, and complete: <br /> Photos x �g gwork Statement <br /> 3. I am authorized to submit this certification eta b <br /> .Ii If 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 T klrowviolations. (HSC 2519 1) <br /> Name: Title:61FF-TV Asemeela 6� <br /> Signature. G#y oSo5 Date: o-a5-0 <br /> F,TAD 22-02-00.5 Rev 12-04 <br />