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12/29/2010 11 : 32 FAX Z001/005 <br /> SAN JOAQiAId COUNTY <br /> ENVIRONMR4 TAL HEALTH DEPARTMENT <br /> 600 East Main Street,Stoclnon,CA 95202-3029 <br /> Telephone:(209)468-3420 Fax:(209)468-3433 Web:mmw gisov orvAhd DEC 2 8 2010 <br /> ucn Lit p DE:'�.i1 <br /> RETURN TO COMPLIANCE CERTIFICATION'S - rr�erqr <br /> Any MINOR violations noted in the"Notice to Comply"in the attached Inspection Report most be <br /> rrected 'thin 30 of receipt of this inspection. This certification form must be submitted to the <br /> Environmental Health Department(EHD)address at the top of this form within 35 days of receipt of the <br /> Inspection Report <br /> Al correc ons too er viol tions noted in the attached Inspecsrion Report(Ht)or Continuation Form or <br /> di utes to any vro tions,are to submitted using this certification and returned to EHD within 30 days <br /> unless otherwise specified in the Inspection Remrt. <br /> Note: All E11D staff time associated with failing to comply by the above noted dates will be billed at <br /> the current hourly rate(S122). <br /> For this certification to be coinplete the operator of the site roust include: <br /> • A statement documenting what corrective actions were taken or will be taken for each violation <br /> • Copies of sample results/manifests/traininon recordsiother appropriate paperwork,and/or photos <br /> venfying corrections <br /> • Operator's certification <br /> Inspection Date: December 1, 2010 Inspected By: Garrett Backus <br /> Facility Address: 4747 West Lane EPA 1D#: CALb00327829 <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. 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_j,/ pBPeiWOrkStatement <br /> 3. lam 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.(IiSC 25191) <br /> Name: i Title: . <br /> Signature: Date: /o <br /> EHD 22-02-005 Rev 08/10 <br />