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N <br /> SAN JOAQUIN COUNTY <br /> ENVINONMr,NTAL HEALT D <br /> T95202-3029 <br /> EPARTmEN <br /> 600 East Main Slreel, StockfonCA 95 02 3029 <br /> Telephone;-(209)468-3420 Fax.'(209)468-3433 Web:www.s oV.or /eh <br /> SEC 22 2010 <br /> RETURN TO COMPLIANCE CERTIFICATION_ y-TH ` ' "•MSL <br /> l H C�idTRR[!VT <br /> Any MINOR violations noted in the 'Notice to Comply"in the attached Inspection Report must be <br /> corrected within 30 da ,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 30 days of receipt of the <br /> Inspection Report. <br /> All correct* <br /> tons 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 EHD Hrithin 30 dam <br /> unless otherwise specified in the Inspection Report. <br /> Note: All EHD staff time associated with failing <br /> billed at the current hourly rate. to comply by the above noted datels will be <br /> For thlS CertifiCc-3tion t0 be COmpiete the operator of the site must include: ' <br /> • A statement documenting what corrective actions were taken or will be taken for each v;iolatibn <br /> • Copies of sample results/manifests/training records/other appropriate paperwork, and/or <br /> verifying corrections <br /> • Operator's certification photos <br /> Inspection Date: <br /> �— �---_� Inspected •Q i3y: <br /> Facility Address: <br /> � � f�-- <br /> c — EPA ID#: <br /> , <br /> I certify under penalty Of law that: <br /> 1. I have corrected the violations specified in the Inspection <br /> inspection date. Report from the above-m <br /> entioned <br /> 2. 1 have personally examined the following documentation submitted as proof of compliance POR <br /> EACH VIOLATION and I believe the information to be true, accurate, and complete. <br /> Photos_ x Paperwork <br /> Statement <br /> 3, t am authorized to submit this certification on behalf of the Respondent. <br /> 4. I am aware that therl>are significant penalties for submitting false information, including the <br /> possibili Ine and/or imprisonment for known violations. (HSC 25191) <br /> Name; l( <br /> Title: <br /> Signature: S —=~I <br /> Date: 12- <br /> 611 22.02406 Rov 10/0B <br />