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SAN JOA4UIN 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.siaov.ora/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 30 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 />Note: All EHD staff time associated with failing to comply by the above noted dates vllll be <br />billed at the current hourly rate of $105 (beginning 8/1/09 the hourly rate will be $115). <br />.-Fo this certification t0 be Complete the operator of the site must include: <br />• A statement documenting what corrective actions were taken or will .be takers 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: i -/ 0 7 Inspected By:1011e461X <br />Facility Address:/s C2,�t��i /l� EPA ID#uf�o 0 3'7,P rd 0% <br />certify under penalty of law that: <br />1. 1 have corrected the violations specified in the Inspection Report from the above-mentioned <br />inspection date. <br />2. I 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 completer <br />Photos 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 25191) <br />Name: Title: <br />Signature:,,„' ` Date: �—� s' <br />EHD 22-02-005 Rev 08/09 <br />