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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.sigov.Qrs� <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 day-S 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 this certification and returned to EHD within 60 dans <br /> unless otherwise specified in the IR. <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/tixaining records/other appropriate paperwork,and/or photos <br /> verifying corrections <br /> • Operator's certification <br /> Inspection Date: — 0 7 Inspect y: —7—AaA V441cr <br /> Facility Address: 7 7Z tdser� -Wor EPA #: Cqk 000 61 ID/a, <br /> I certify under penalty of law that: n j( <br /> ®R. AM %N 44."-yftd 00-cs a Q` C-64"6'� <br /> 1. I have corrected,4he violations specified in the Inspection Report Pm 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 V Paperwork Statement <br /> 3. 1 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: k r-g 4 / * c4% O�/J. 4 A,ts <br /> Signature: 7!� Date: `/— /:3 — 07 <br /> EHD 22-02-005 Rev 05/07 <br />