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SAri�ifs �'pitlCot�tv'ry - <br /> PWIRONMENTALHEALTH MPARTMENT <br /> 304 Bast'Weber Avenue,•a f Flooro$tocktoiy,CA 45202-2708 <br /> Telephone:(209)465-3d' 0'P= (209)468-3433 Web:wwwsjeoy.om/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 dans of receipt of this inspection, This certification form must be submitted to the <br /> Environmental Health:Dep at c►eut-(EM).address at the top of this form wither 39:days of receipt•ofthe <br /> inspection report. <br /> All corrections wother violations noted in the attached Inspection Report(IR)or Continuation Foiw;or <br /> d>sl5utes anx vaolatlofs;psik ba subuutted us%mg &eitifica4ion,and rettuned to.EJB]vntlun:'60 dans <br /> unIess!otlxetivise;speci8ed initis ITS <br /> For this 'Gi✓i0cat ft.to be CO Mplete the.operator of the site must include: <br /> • A statement documenting what corrective actions were taken or will.:betaken for each,viotation, <br /> • Copies of sample;results/manifests/training recordrs/other appropriate paperwork,and/or photos <br /> Va., <br /> correchona. <br /> • erator s certttiGstion, <br /> ., <br /> :InsPec„teB at:!Aji�!✓1. <br /> Facility A ers q o/S r a pec 4.1 EPt > #;. . <br /> OF <br /> T.certify.u,66A.P: nalty.oflawthat' <br /> 1. I have+ �, tlieviolaftons specified iii the.Insgection Report firm he above.meatitin�d <br /> rispehtioh:rim. : . ., <br /> 2. X have personally eiCatntpe it fo lowricg l00W.”!ntation submitted'as•proof of eoriiplza>rcd FQR <br /> EAIIIOLtIICtf+1 ancishelre ia#oiftoff tabs tri .xGCUiate>and complete <br /> lsfiotos 1'apevwikStatement <br /> 3. I am authorized to submit this certification on behalf of the Respondent. <br /> 44. I am aware that there are significant penalties for submitting false:info.,rmadoiu iYit`li{ <br /> possibjlity of a fine and/or imprisonment for known violations <br /> Name: Title: <br /> Signature: Date:. <br /> EHI7 22-02-005 Rev 12-04 <br /> f Wd9920 S00z 2T 'AUW OLL9 064 BSS 'ON 3NOHd MDIW 031 : WOdd <br />