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SAN •>. COUNTY a <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />•Lt East Main Street, Stockton, CA 95202-3029 <br />Telephone: (209) 468-3420 Fax. (209)!468-3433 Web: www.sigov.orn/ehd <br />RETURN <br />• COMPLIANCE CERTIFICATION <br />1*1611Kz1"(z4 WTA 11111111M 1111W16 <br />Lfre GAI 74-trins iorm Tutnin W11 uaj,5 at recelpt OT <br />Inspection -•• <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 />• All EHD staff time associated with failing to comply • the above noted dates will • <br />billed at the current hourly rate ($105). <br />For this certification to •' completethe operator • 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 cercation <br />I 11ITTM-Mr. in <br />Inspected By: <br />Facility <br />•• EPA ID#: <br />1. 1 have corrected the violations specified in the Inspection Report from the above-mentioned <br />inspection date. <br />11 -6 Z 0 so 0 oil 0 <br />Photos Paperwork Statement <br />ip�ij� 1111I�Ilw I <br />Name: Title: <br />71 -T= - <br />EHD 22-02-005 Rev 08108 <br />ME <br />