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SAN JoAQm COUNTY <br /> ENVIRONMENTAL HE,A UA-H DEPARTMENT <br /> 600 E.Main St_,Stockton,CA 95202-3029 <br /> Telephene:(209)468-3420.Fax:(209)468-3433 Web: ' -' v <br /> 6qy§y5y6 N <br /> RETURN TO CO MANCE CERT1F1GX 11 <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 for6i ust 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_dda. <br /> unless otherwise specified in the Inspection Report. <br /> Vote: All EHD staff time associated with failing,to comply by the above noted dates will be billed at <br /> the current hourly rate($122). <br /> For this certification t0 be COMPIete the operator of the site must include: <br /> • A statement documenting what corrective actions were takea or will be taken for each violation <br /> s Copies of sample results/manifests/training records/other appropriate paperwork, and/or photos <br /> verifying corrections <br /> • Operator's certification <br /> Inspection Date: 1 ` Inspected By: tact' Rivera <br /> Facility Address: 0 P l � v� EPA ID#: <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. 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 /> 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 25191) <br /> Name: CPA Rtt N S N1 r� Title: 0 W t4 <br /> Signature: G � � �' D;9�" j n Date: A r' r <br /> EHD 22-02-005 Rev 08/10 <br />