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SAN JOAQUIN COUNTY <br /> ENVMONMFNrAL HEALTH DEPARTMENT <br /> 600 East Main Stockton.CA 95202-3029 <br /> Te%nkone.(209)468-3420 Fax.(209)468-3433 Web.vwvw,siov orjz/thd <br /> R TURN TO COMPLIANCE CERTIFICATION <br /> Any MINOR violatiZlys <br /> s noted in the'Notice to Comply"in the attached Inspection Report must be <br /> corrected within 30 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 35 days of receipt of the <br /> Inspection Report. <br /> AlFcorrectiops to other violations noted in the attached Inspection Report(IR) or Continuation Form, or <br /> dispputes to any vto ati ns,are to submitted using this certification and returned to EHD within 30 days <br /> unress otherwise specified in the Inspection Report. <br /> Note: All EHD staff lime associated with failing to comply by the above noted dates will be billed at <br /> the current hourly rte($122). <br /> For this certlflatlon to be complete the operator of the site must include: <br /> • A statement d umentingg what corrective actions were taken or will be taken for each violation <br /> • Copies of s pie results/manifests/training records/other appropriate paperwork,and/or photos <br /> verifying carr tions <br /> • Operator's cc ification <br /> A� 7�nG 4"5 LfS4 <br /> Inspection Date: ' z 6- - 2 `` Inspected By: <br /> Facility Address: �5:5 11 S. S U l 4cr St EPA ID#: <br /> 1 certify under pe lty of law that: <br /> 1. I have correct the violations specified in the Inspection Report from the above-mentioned <br /> inspection dat . <br /> 2. I have personally examined the following documentation submitted as proof of compliance FOR <br /> EACH VIOLITION and I believe the information to be true,accurate,and complete: <br /> _Photos Paperwork f Statement <br /> 3. I am authorized to submit this certification on behalf of the Respondent. <br /> 4. 1 am aware tha there are significant penalties for submitting false information,including the <br /> possibility of afine and/or imprisonment for known violations. (HSC 2519 1) <br /> Name: ���t��J ��:Jr. Title: <br /> Signature: t6 Date: a - z <br /> EHD 2202-005 Rev 0 10 <br />