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FEB/22/20CYTHU 06: 34 AM FO OR LESS WH. FAX No, 1209$6$ 8 P. M <br /> SAN JODAQUrN COUNTY <br /> ENVRZONMENTAL HEALTH DEPARTMENT <br /> 304 East Weber Avenue,3'a Floor,StocktoV,CA,95202-2718 <br /> Telephone:(209)468-3420,Fax,(209)468-3433 Web:www.qjgoy,qrg/ehd <br /> RETURN TO COMPLIANCE CERTIFICATION <br /> Any MINOR violations noted in the"Notice to Comply"in the attached inspection repori must be <br /> corrected within 30 days 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 /> All corrections to other violations noted in the attached Inspection Report(IR)or Continuation Forin,.or <br /> disputes to any violations, are to be submitted using this certification and returned to MID within 60 days <br /> unless otherwise specified in the 1R. <br /> For this certification t0 be complete the operator of the site must include:' <br /> • A statement documenting what corrective actions were taken or will be taken for each violation <br /> • Copies of sample results/manifests/training records/other appropriate paperwork, and/or photos <br /> verifying corrections <br /> • Operator's certification <br /> Inspection Date: r Inspected By:s-r�ve <br /> Facility Address: Z Y9:? 's� EPA ID#: <br /> I certify under penalty of law that: <br /> 1. T have corrected the violations specified in the Inspection Report from the above-wQntioried <br /> insp6ctioa date. <br /> 2. X 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 _Papeiivgrk_Statement <br /> 3. I 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,includmi g the <br /> possibility of a fine and/or imprisonment for known violations, (HSC 2519 1) <br /> -t P <br /> --- Title: / <br /> `'jc`lZl� <br /> 4 <br /> Slgnaturc. Date: —p <br /> EHD 22-02-005 Rev 12-04 <br />