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- _ .. ry. •�-'1�' "`"TrW"!Myoar'�*P"tr,Nl'�M!•11N'111�1"� . .. :fir .m:.:+: <br /> � i `:"t;i l'f !TIf 1. ry4.i !i-�ti':,tflre:,, 4;rtd rti5t)1l (11 (t`fu•,' _. <br /> . ... ^.._�•, M,w'!t.�',. E.", , :ctr.;$ANJUA0UI4 COUNTY 3 ?A IJ ;.`Ut .' iA4!..A <br /> ENVIRONMENTAL HEALTH DEPARTN[ENr <br /> F I JF,atir�b�;tt, <br /> 304 East Weber Avenue,36 Floor,Staekion,CA 9526T-1708.' , ... . . . •... . <br /> TdI rphene:(209)468-3420 Pe=(209)46&3433 Web:www gj <br /> RETURN TO COMPLIANCE CERTIFICATION <br /> Any MINOR violations noted in the"Notice to Comply"in the attached'inspection reportmust be <br /> corrected within 30 days of receipt of this inspection. This certification form must be submitted to the <br /> Environmental Health Department(EBD)address at the top of this form within 35 days of receipt,of the <br /> inspection report. 1. <br /> All corrections to other violations noted in the attached Inspection RepoR`(IR)br' ateLloii Form, i* .71 <br /> disputes to any violations, are to be"submitted using this certification and ireturnea bo M yj ft 60 days <br /> unless otherwise specified in the IR. <br /> r <br /> For this pertification to'be complete the operator of the site must dude t <br /> • A statement documenting what corrective actions were taken or will be taken for each violation 1 <br /> • 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-, <br /> 71 <br /> 1,1) * r1111 l t.4 <br /> Facility Address 4;' `� EPA <br /> r;i ^'i'!�^� t TI W r u 4 ..04w IVU •t SS <br /> y,nd y 1.,d un1,4.nwjrk 1wr Iq Wt Atm, oi,rn9 tmomi tv Ht 12 ; M)":F4 r F1 <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 /> V Photos i� Paperwork Statement <br /> 3. I am authorized to submit this certification on behalf of the Respondent: ; <br /> 4. I am aware,that there a>a sgm6camtpeties for subml;ttigg,false information,incl the <br /> posarbility of a 5ne and/or imprisonment for known violations =FISC 25191) ; <br /> A31: '0 <br /> s1.: 'rE:rllrw Lu!I>e»r i^!' ':Y+fr.l1 n t,t r:r,rlf, , Iuy1p" t.N 17 VdW , .`YD t•,.A�-�, '__. _ <br /> it '. .. '. (.•. l <br /> Name: A-LeC `4-t''1= :L 'Lytle <br /> Signature: Date: -I J�ro, <br /> EHD 22-02-005 Rev:.L2-1)4 <br />