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SAN JOAQUIN COUNTY <br /> Ewv[RONmETTAL HEALTH DEPARTMENT <br /> 600 East Main Street,SWcklon,CA 95202.3029 <br /> re&pbone:(209)468-3420 Fax(209)468-3433 Web:www.siaov.or¢/ehd <br /> RETURN TO COMPLIANCE CERTIFICATION <br /> Any MINOR violations noted in the"Notice to Comply"in the attached Inspection Report must be <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 within 35 days of receipt of the <br /> Inspection Report. <br /> All carrecti s to other violations noted in the attached Inspection Report(IR)or Continuation Form,or <br /> disputes to any violations, are to be submitted rising this certification and returned to EHD v_idlin 30 dava <br /> unless otherwise specified in the Inspection Report. <br /> Note: All EHD staff time associated with failing to comply by the above noted dates wN be billed at j <br /> the current hourly rate. <br /> For this certification to be complete the operator of the site must include: <br /> • A statement documenting what correcF.ve actions were taken or will betaken 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 /> i <br /> Inspection Date: - -09 Inspected By: R Aj VoN FL-oC <br /> Facility Address: 4�fl �,1,�4wr=e�G->T.SZOc�T°N EPA ID#: CADg81 1515 j <br /> LA g52o3 <br /> I certify under penalty of law that: <br /> 1. 1 have corrected the violations specified in the Inspection Report from the above-mentioned <br /> inspection date. I <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 ✓ 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 known violations. (HSC 2519 1) <br /> S�s c1K r l�z <br /> Title: PLArk7 <br /> Name: ntRG C� <br /> Si Date: <br />