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SAN JOAQUIN COUNTY ENVQI1,0NMENTAL HEALTH DEPAkTMENT 304 last W461.T Avenue, Yd Floor, Stockton, CA 95202-2708 Telephone: (209) 406-3420 Fix: (209) 468-3433 Web: www,siggyqrehd RETURN TO ,COMPLIANCE CERTIFICATION Any MINOR violations noted in the' Ai Aice to Comply" in the attached inspection report must be corrected within 30 days of receipt of this inspection. This certification form must be submitted to the Environmental Health Department (ERD) address at the top of this form within 35 days of receipt of the inspection report. All corrections to other violations noted in the attached Inspection Report (IR) or Continuation Form, or disputes to any violations, are to be sutra -pitted using this certification and returned to EHD within 60 days unless otherwise specified in the 1R_ For this certification to be complete the operator of the site must include: • A statement documenting what ,„orrective actions were taken or will be taken for each violation o Copies of sample results/maniksts/training records/other appropriate paperwork, and/or photos verifying corrections • Operator's certification Inspection Date: r� Cl %� Inspected By: Facility Address: 3� ZS ��”' EPA ID#: I certify under penalty of law that: Vi ti �A �Jq 1. I have corrected the violations �.:)ecified in the Inspection Report from the above-mentioned inspection date. 2. I have personally examined the "ollowing documentation submitted as proof of compliance FOR EACH VIOLATION and I believe the information to be true, accurate, and complete: Ph+ otosPaperwork Statement 3. 1 am authorized to submit this certification on behalf of the Respondent. 4. I am aware that there are signifx.ant penalties for submitting false information, including the possibility of a fine and/or impoiwriment for known violations. (HSC 25191) Name:y +N zoW 4,a��2 Title: �(yj) M W_ _ µ EHD 22-02-005 Rev 12-04 Z9 39dd Date: vi ..,1 % - 8L9L588 b0:t0 Le9Z/ZT/be