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09/22/2006 14:17 2094683433 EHD PAGE 04 <br />• SAS-t9AQUIN COUNTY <br />"ENVIRONMENTAL 14EALTH DEPARTMENT <br />304 East 'Weber Avenue, 3*4 Floor; StQgkton, CA 95202-2708 <br />Telephone. (209) 468-3420 Fox: (209) 468-3433 Web. 2nM-Sj ov.or /ehd <br />RETURN TO COMPLIANCE CERTIFICATION <br />Any MINOR violations noted in the "Notice to Comply" in the attached. inspection repoft:dlwt be ' <br />corrected within 30 da 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 Mthin 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 days <br />unless otherwise specified in the 1R. <br />OP t%1S certification t0 be COMPIete the operator of the site roust include: <br />• A statement documenting what corrective actions were taken or will be taken for each violation <br />• Copies of sample results/rnani.fests/training records/other appropriate paperwork, and/or photos <br />verifying corrections <br />• Operator's certification <br />Inspection Date: F5*1— F1,3 — Q ' <br />Inspected By: o u,q g�✓,�.,._ <br />Facility Address: 0 2 g'S )E'. 1;�k'vovS EPA ID#: 66 Q d qS Wq <br />5A C,kTte" <br />I certify under penalty of law that: <br />L 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 Vll�Staternent <br />3. I 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 itnprisonrnent for known violations. (HSC 25191) <br />Name:,i K ��.Q2!/�,= �d Title: 4i2ereym , '05/a. �qr' les <br />Date: '/— 7i %— 6 to <br />EHD 22-02-005 Rev 12-04 <br />a <br />