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S&46 COUNTY <br /> BNVIRONI `i'rl4 rMAL7HDEPARTMENT <br /> 304 East Weber Avenue;-3'd F1oor,.Sfaekton CA 95202-2708 <br /> I,elephont:.(209)448-3420 Pain(209)468-3433 Web:w .sjgmLog/ehd <br /> RET $1%O,COMPLIANCE CERTIFICATION <br /> Any W90k violations uoW+'in thr,"Notiee to Comply"in the attached inspection report must be <br /> cotrected,within 30days of receipi of this inspectiom, This certification form must.be subnutted'to t <br /> Environmental Health D4*tMent(EHDj.addrrbss,at the top of this form�vixhir;.35 days ofreceipt of the . <br /> inspection report. <br /> ,All corrections:to other violations noted in the attached Inspection Report:(IIZ).or Cgnti kixatioj ''Eotm�oz.. <br /> disputes to any.viol#ipnsj are;to be submitted,usmg this certification and t fie to IIID thui O days;, <br /> unless:�therwxsespeax'beditt''tlxe lR. <br /> For:1115 Ord-fica'...v -t be. C6I11p1do the operator of the site:raust include: <br /> . A statement documentuig w*corrective actions were taken or will be taken for each v;Aq ai inm <br /> •-: Copies.6r.sa mpwresults/manifesWUshiingrecords/otherappropriatepaperwork,;and/o plic}Igs <br /> velify¢�fg, grrpotlons„ <br /> •.;�Qperutor's,ceXti"B,gatiath .. .,::,°..' ,,. : ' <br /> Inspechtln late /l ai IrlsgecSed>By: A��M . <br /> - <br /> � ; . <br /> Pad* dies 1 W. I; aR�► EI'AII3t#: <br /> I cent" e &natty of3ag; at: <br /> lhe'violations specified in the Inspection Report front tlie.abave mentlbncd; <br /> mspecUafr�lat>s . <br /> 2. 1 have p. tsat1* ly.examined the following documentation submitted as proof of compliance FOR. <br /> EACFIf,M.QN aftd I believe the information iv be true,accurate,and complete. <br /> Phptos 1'ape work t/ Statement. <br /> 3. I am authoiizeii ib submit tans cerh5catton p behalf of the Respondent. <br /> 4. lam aware that therm ate tupnificant,peualtre&for.submitting fa1Se YZifomahon,>nel>�`tg the <br /> possibility o£a£tte and/or unprtsonment faf kpowm viol,atiaris (TIBC 2S1 .t] <br /> D Title: <br /> Name. _ a .wi+J, ,L � e✓` <br /> S <br /> ate: <br /> gxult.W, <br /> EHD 22-02-005 Rev 12-04 <br /> SWdt3S:Z0 S00Z ZT •AUW OU9 067 OTS : 'ON 3NOHd 060IW 931 W063 <br />