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NOV-13-2013 15:15 From: 2098254549 To:4663433 Pase:l�l <br /> � <br /> SAN JonQatN COUNTY >j <br /> East <br /> Weber Avenue,3' <br /> Floor, <br /> HEALTH DEPARTMENT <br /> 952 <br /> 304 Ea0 )468-3420 Fay. <br /> -(20 )468-3431 Web; <br /> vaL02-2708 RECEIVED <br /> Telephone (209)468-3420 Far:(209)468-3433 Web;�ww�go�ehd <br /> 12 3 <br /> RETURN TO COMPLIANCE CERTIFICATIO*NVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> Any MINOR violations noted in the"Notice to Comply"in the attached inspection report 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 Form, or <br /> disputes to any violations, are to be submitted using this certification and returned to EHA within 60 days <br /> unless otherwise specified in the IR. <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:___e a " � ec e <br /> Facility Address:- �-. �( ,2Prl EPA ID#: Q(Xj2 <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 Paperwork Statement <br /> 3. 1 am authorized to submit this certification on behalf of the Respondent. <br /> 4. 1 am aware that there are significant penalties for submitting false information, including the <br /> possibility of a fine and/or imprisonment for known violations. HSC 25191) <br /> Q (.0 L_ -- flu-W C-1t' LOCL- -(A f&Ak 4444-td-A <br /> Name: TIIAAAceA) S SLo BOG+ t_Title:-meq) A <br /> Si afore: Date: <br /> EHD 22-02-005 Rev 12-04 <br />