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04/27/2011 WED 15: 22 FAX 2092' '433 S,7C EHD ��� IQJu01/001 <br /> MCAr►•r^� <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL.HEALTH DEPARTMENT <br /> 600 E.Main.St.,Stockton,CA 95202-3029 <br /> Telephone:(209)468-3420 Ea=(209)468-3433 Web: ._5jjov ehd <br /> RETURN TO COMPLIANCE CERTIFICATION <br /> Any MIN R violations noted in the"Notice to Comply" in the attached Inspection Report must be <br /> corrected within 30 daa s 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 /> All corrections to other violations noted in the attached Inspection Report or Continuation Form,or <br /> disputes to any violations, are to be submitted using this certification and returned to EHD within 30 days <br /> unless otherwise specified in the Inspection Report. <br /> Note: All EHD staff time associated with failing to comply by the above noted dates will be billed at <br /> the current hourly rate ($122). <br /> For this certification to be complete the operator of the site must include: <br /> • A statement documenting what corrective actions were taken or will be taken for each violation <br /> e Copies of sample results/manifests/training records/other appropriate paperwork, and/or photos <br /> verifying corrections <br /> • Operator's certification <br /> Inspection Date:_ Inspected By: N <br /> Facility Address: 34A C • ftct,%�% Sr� EPA ID#:r--* <br /> iL t P Ova C-A- aa7'3 !� <br /> I certify under penalty of law that: <br /> 1. I have corrected the violations specified in the Inspection Report from the above-mentioned <br /> inspection date. <br /> 2. I have personally examined the following documentation submitted as proof of compliance FOR <br /> EACH VIOLATION and I believe the information to be true,accurate,and complete: <br /> Photos ✓Paperwork staterne <br /> u.d- S r3.�..e-N- /fes uti�.e,..'�'L• <br /> 3. I am authorized to submit this certification on keh if o the Respndent. <br /> 4. I am`�rle tre igKidpanFpen ties or sub�hitting false information, including <br /> possibility of a fine and/or imprisonment for known lsC 5191) <br /> �3 <br /> Title: <br /> Mame: <br /> Signatu Datej� <br /> Lj <br />