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I • • <br /> SAN JOAQUIN COUNT\ <br /> ENVAONML•NTALREALTI I OEPAW MENT <br /> 600 Gust Main Street,Stockton.l:'A 75202.3029 <br /> Telephane,(209)468-3420 Fax;(209)463.7433 Web:www. 'rov.nrWhd <br /> RETURN TO COMPLIANCE CERTIFICATION <br /> Any ballo 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 /> Envinmmental Heald, Department(EHD) address at the top Of this form within 35 days ofreeLipt of the <br /> Inspection Report. <br /> All corrections to other violations noted in the attached Inspection Report(1R)or Continuation Form, or <br /> disputas to any violations,are to be submitted using this certification and returned to EHD within 30 days <br /> unless otherwise specified in the Inspection Report. <br /> Note: All LHD staff time associated with failing to comply by the above noted dates will he billed at <br /> the current hourly rate($122). <br /> For lh1S certification t0 be complete the operttnr 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 /> F <br /> tion Date: rsL ttInspected By:ty Address:1iL CL 14W EPA I D#: <br /> rtify under penalty of law that: <br /> 1. 1 have corrected the violations specified in the Inspection Ituport from the above-,mentioned <br /> inspection date. <br /> 2. 1 have personally examined the following documentation iubmitted as proof of compliance FOR <br /> 13ACH VIOLATION and 1 believe the information to be true,accurate,and complete: <br /> Photos )c Paperwurlcf Statement <br /> 3. 1 am authorized to Submit this certification on behalf ot'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 imprisomnent for(mown violations.(HSC 25191) <br /> Narrte:� <br /> .� (�7• ^ ride,_.. arc t/ <br /> Signature: 7 � nate: <br /> EIID 22-02-005 Rev 08110 <br />