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0 JOAQUI C®C,"t�r�' <br /> ENVIRON ENTAL HEALTH DEPARTMENT � <br /> 600 E.M in St,Stockton,CA 95202-3029 <br /> Telephone_(209)468-34 Fax:(209)468-3433 Web:www.sjg0V.0rP-/Ch <br /> RETURNTOCO LIANCE CERTIFICATION <br /> Any MJN'O violations noted in the"Notic to Comply"in the attached Inspection Report mustbe.. <br /> corrected wi in30 da of receipt of this 11,spection. This certification form must be submitted to the <br /> Environmen &I Health Department(ERD) dress at the top of this form within 35 days of receipt of the <br /> Inspection port. <br /> All q_qrreqtic is to other violations noted in a attached Inspection Report or Continuation Form,or <br /> disputes to a y violations,are to be subrai d using this certification and returned to EHD within 30 days_ <br /> unless other ise specified in the Inspectio Report. <br /> Note: All E ID staff time associated witt failing to comply by the above noted dates will be billed at <br /> the current ourly rate($122). <br /> For this ertification t0 be coplete the operator of the site must include; <br /> • A st tement documenting what co ective actions were taken or will be taken for each violation <br /> e Cop es of sample results/manifests ining records/other appropriate paperwork,and/or photos <br /> ver' ying corrections <br /> • Ope tor's certification <br /> Inspection ate: on E, t 0 C% E Inspected By: <br /> ' c EPA ID#: irCC'°Q ' ;' 1 <br /> Facility A dress: •w ^;° t�• .i, e � � <br /> ~� -aci'l � 1� '�+ Biu. Oi `l <br /> I certify under penalty of lave that: <br /> 1. 1 ha a corrected the violations spedfied in the Inspection Report from the above-mentioned <br /> insp tion date. - <br /> 2. 1 ha a personally examined the fol wing documentation submitted as proof of compliance FOR <br /> EA H VIOLATION and I believe he information to be true,accurate,and complete- <br /> Photos Paperwork Statement <br /> 3. Ian authorized to submit this cern ication on behalf of the Respondent. <br /> 4. larr aware that there are significa penalties for submitting false information, including the <br /> pos bility of a fine and/or imprisal anent for known violations. (HSC 25191) <br /> Name: Q !ie. i� C fCL Title: <br /> Signa e: hate: - "�- <br /> : , <br /> .EHD 22-02 05 i i <br />