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FROM FAX NO. :2093699162 c. 02 2009 10:17AM P3 <br />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: 4jvvw.sigov.qrg/ehd <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 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 3a 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 30 days <br />unless otherwise specified in the Inspection Report. <br />Aote: All, EHD staff time associated with failing to comply by the above noted dates will be <br />billed at the current hourly rate of $1 05'(beginning 8/11/09 the hourly rate will'60 <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/training records/other appropriate Paperwork, and/or photos <br />verifying corrections <br />• Operator's certification <br />Inspection Date: Inspected By:. <br />Facility Address: <br />I certify under penaltyof law that:: <br />EPA ID#: <br />1. 1 have corrected the violations specified in the Inspection Report from the above4nentioned­ <br />inspection date. <br />2. 1 have personally ekamirie;d the following documentation submitted as proof of compliance FOR <br />EACH VIOLATION andl -believe the information to be true, accurate, and complete: <br />Photos Paperwork 'Statement <br />1 am authorized to submit this certification on behalf of the Respondent. <br />4. 1 am aware that there are sign . ificant penalties for submitting Nise information, 'including.the <br />possibility of a fine and/or imprisonment for known violations. .(HSC 26191) <br />Title: <br />Date: <br />EH0 22-02-005 Rev WM <br />