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RECENEU <br /> SAN JOAQUIN COUNTY <br /> ENVIRONME14TAL HEAL'M ENVIRONMENTAL HEALTH DEPARTMENT <br /> PERM171SERV{CES Telephone.(2( ) 300 East mainFax�2 � 8°3 33 We2b?-36-29 <br /> www.si�ov.org/ehd <br /> RETURN TO COMPLIANCE CERTIFICATION <br /> Any MINOR violations noted in the`notice to Comply'in the artached inspection Report must-De <br /> corrected within 30 days 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 vrithin 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 retumed 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 /> • Copies of sample results/manifests/training records/other appropriate paperwork,and/or photos <br /> verifying corrections <br /> • Operator's certification <br /> Inspection Date: =?�✓1 1 l Inspected By: Stacy Rivera <br /> Facility Address: 3,5 �, Ra�c'_ai EPA ID#: <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 �-- P aperwork ✓ statement <br /> 3. I am authorized to submit this certification on behalf of the Respondent. <br /> 4. I am aware that there are significant penalties for submitting false information,including the <br /> possibility of a fine and/or imprisonment for kno violations. (HSC 25191) <br /> C / <br /> Name: '� C'�- �� V Title: a X9,1 <br /> Signature: <br /> EHD 22-02-005 Rev / 0 <br />