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_�. --. �•••••• �• •�. LV� l00�4JJ EHL) PAGE 02 <br /> SAN JOAQM COTJNTY <br /> ENVIROVM&NTAL HEALTH DEPARTMEM <br /> 304 Easy Reber Avemm, 3t°Floor;Stockton,CA 95202-2708 <br /> Telephone:(209)46$-34201C'nx:(209)468-3433 Web;wwW.sjgov.orelehd — <br /> R- TURN TO COMPLIANCE CLRTIFYCAT'XON <br /> Any MINOR violations noted in the'Notice to Comply,,in the attached inspection report must be <br /> corrected within30 dam of receipt of this inspection, This certification form must be submitted to the <br /> Environmental Health Department(ERD) address at the top of this form within.35 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 60 da <br /> unless othemise specified in the a <br /> For this certification to be COZY p ete the operator of the site must include: <br /> A statement documenting what corrective actions were taken or will be taken for each violation <br /> Copies of sample results/manifests,'haining records/other appropriate paperwork., and/or photos <br /> verifying corrections <br /> • Operator's certification <br /> Fection Date:[ z 3 0 6 Inspected Ey: <br /> 7 <br /> lity Address: V 7 0 7 Pa c" '-c 4vc � EPA ID#: r A L_ 0 O 0 2 3 Z I F1 <br /> I certify under penalty of law that. <br /> 1. 1 have corrected the violations specified in the Inspection Report from the above mmtioned <br /> inspection date. <br /> 2. 1 have personally exam-ined the follow4 documentation submitted as proof of compliance FOR <br /> EACH VIOLATION and I believe the information to be true,accurate,and complete: <br /> Photos--L--Paperwork Statement <br /> 3. 1 am authorized to submit this certification on behalf of the Respondent. <br /> 4. lam aware that there are significant penalties for submitting false information, including the <br /> possibility of a fine and/or imprisonment for known violations. (HSC 2519 1) <br /> Name: 7e ;Icv Title: l' !^ <br /> 4 f C hl/��oL7inrhtq 6 jjjqoq, <br /> Myv <br /> Signature: Date: 2 2� <br /> EHD 2202-005 Rev 12-04 - <br />