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12/13/2012 22: 13 2098322051 BARBOSA MAINTEN$NCE PAGE 01/04 <br /> AN JOAQUIN COUNTY RECEIVED <br /> ENvmON1.111 TAL HEALTH DEPARTKENT <br /> 600 F.main st.,stoddo*4 CA 95202-3029 <br /> 9elepborre:(209)468-34 0 Fax:(209)468-3433 Web:wW% ov.or e DEC 14 2012 <br /> NMENTAL <br /> HEALTH DEPARTMENT <br /> RETURN TO COiMPLL8NCE CERT>Ck'ICATION <br /> Auy NIINO violations noted in the"Notide to Comply"in the sttsched Inspection Report must be <br /> corrected '-mj �r 30 da of receipt oT this inspection. This certification form must be submitted to the <br /> Environmental Health Department(EHD)address at the top of this form witbin 35 days of receipt of the <br /> Inspection Report. <br /> All corrections to other violations notedva Ithe attached Inspectitm Report or Continuation Form or <br /> disputes to any violations,are to be submitted using this certification and returned to EFiD within 30_ M <br /> unless otherwise specified in the Inspection Report. <br /> Note: All EHD staff time associated wlt� failing to comply by the above noted dates will be billed at <br /> the current hourly rate(S119). <br /> For this certification to be cdlImplete the operator of the site must include: <br /> • A statement documenting what cozrective actions were taken or will be taken for each violation <br /> • Copies of sample results/manifestshraining records/other appropriate paperwork,and/or photos <br /> verifying corrections <br /> • Operator's certification <br /> Inspection Date: (7fC 13. 01 2 Inspected By::`r H U YILA/✓ <br /> Facility Address: 20 a k D. EPA ID#: CA R, 0 OO 1 66i ) 3 <br /> TRAtY' CA 91s3vq <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. <br /> 2. I have personally examined the foljowing documentation submitted as proof of compliance FOR <br /> EACH VIOLA'T'ION and I believe the information to be true,accurate,sad complete: <br /> Photo§ %/ Paperwork Statement <br /> 3. I am authorized to submit this certification on behalf of the Respondent. <br /> I <br /> 4. 1 wu aware that there aro signitxcar�t penalties for submitting false information,including the <br /> possibility of a fine and/or imprisob went for known violations.(HSC 25191) <br /> Name: /4,9XK 6sl�balfiq _Title: /��4rnr" �+ F� <br /> Signature: Date: <br /> EHD 22-02-005 Rev 08/10 <br /> I <br />