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SAN JOAQUIN"LAITY <br /> ENVIRONMENTAL HEALU DEPARTMENT. <br /> .600 East Main.Street,Stockt6n, CA 95202-3029 <br /> Toephoi ie.-(209)468 <br /> -3420 Fax-(209)460-3433 Web:www.sjgoy.oMLehd <br /> RET U RN TO COMPLIAN4E CERTIFICATION <br /> Any MINOR violations noted in the"Notice to Comply"in jhe attached Inspection Report must be <br /> corrected within 30 dans of receipt of this inspection. Thij certification form must be submitted to the <br /> Environmental Health Department(EHD)address at the tbp of this form*within 30 days of receipt of the <br /> Inspection Report. <br /> All corre!Aions to other viol,I=noted in the attached Inspection Report(IR)or Continuation Form, or <br /> disputes to any Violations, i ire to be submitted using this 4ertification and returned to EHO within 30 days, <br /> unless otherwise specified n the Inspection Report. <br /> Note: All EHD staff tim associated with failing t�comply by the above noted daites'will be <br /> billed at the current hourly rate. <br /> For this 'certification to be completd the operator of the site must include: <br /> • A statement documenting what corrective actions w re taken or will be taken for each violation <br /> • Copies of sample rest.Its/manifests/trAining records/pther appropriate paperwork.and/or photos <br /> verifying corrections <br /> Operator's certificatior i <br /> Inspection Date: 6 i InspectedU q—I-CA <br /> By: <br /> Facifity'Addressi: 4-Q-;PA iD*-. <br /> I certify under penalty of law that- <br /> I I have corrected Mh violations specified in the Inj pection Report from the above-mentioned <br /> Inspection date. <br /> 2. ),have personally examined the following documqnta#w'submifted as proof of compliance FOR <br /> EACH VIOLATION!and I believe the information Ilo be true,accurate, and complete: <br /> Photos � Papirwork' Statement <br /> 3. 1 am authorized to 3ubmit this certification on betolf of the Respondent. <br /> 4. 1 am aware that there are significant penalties for'isubmiffing false information, including the <br /> possibility'of a fine and/or imprisonment for knowh violations. (HSC 25191) <br /> A <br /> Name: bass U0 e- <br /> a-i ��G�-tY1tIcx-OeL e-,/ <br /> Signature: Date: <br /> .. ENO 22-02405AiY-1'010 <br /> 10/10 39Vd 1731-G S3j3r 13 89689EB60ZT LP:TT 8102/10/90 <br />