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_ . Yeti <br /> Mvp' • EUVEM• <br /> I. L% ENVIRARTMENT <br /> K �e5rt, CA 95202-3029 L 3 'GO10 <br /> 600 East <br /> s y Telephone:(209)468-3,47: nB-3433 Web:www.sioov.ora/ehd <br /> ENVIRUNI��ENT HEALTH <br /> RETURN TO CV 1 LJ'ANCE CERTIFICATION <br /> =. .:=dations noted in the "Nc " in the attached Inspection Report must be <br /> ~in 30 days of receipt of This certification form must be submitted to the <br /> s;:e=nal Health Department(Ei re top of this form within 30 days of receipt of the <br /> `l+eport. <br /> s to other violations nc.e,: - Yd inspection Report (IR) or Continuation Form, or <br /> 6 any violations, are to be sucrnaue ^fang,this certification and returned to EHD within 30 days <br /> es4kkherwise specified in the lnspe ri _- <br /> -r All EH®staff time associate: with failing to comply by the above noted dates will be <br /> billed at the current hourly rate, <br /> s mis certification to be Coo plete the operator of the site must include: <br /> statement documenting vv�=- c s actions were taken or will be taken for each violation <br /> ,copies of sample results m = g p records/other appropriate paperwork, and/or photos <br /> erifying corrections <br /> Operator's certification <br /> Inspection Date: Inspected By: <br /> Facility Address: GOON GLt (l EPA ID#:l/F <br /> I certify under pore '.teat: <br /> 1. I have corrected the io!azions specified in the Inspection Report from the above-mentioned <br /> inspection date. <br /> 2. 1 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. 1 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 25191) <br /> Name: �o 11 t fit 99� I Title: 1)ZZ)1?e�,P, <br /> Signature: ,`' -- Date: <br /> .EHD 22-02-005 Rev 10109 - <br />