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zvu j:arm Sa. joaquin Cr,unfy <br /> SAN JOAQM C0L'1VTl' <br /> >~rrvtHoNWWTat,HEA.L;cN,DRPA.RTMEI+IT <br /> EIVED <br /> 304 East,Weber Avenue,3'v Floor,StOcl7024 CA 95202-2708 <br /> Telephone:(709)468,34a Fax:(209 458 r EC <br /> 343_ ►deb. w <br /> -w s ohd <br /> RETURN" TO COMPI.XA.NCE CERT114cA'Z'ION SAN JOIAQUIN RONMENOTALTM <br /> ABy MZi0_R vin1ations noted the"Notioe HEALTH DEPARTMENT <br /> corrected ri 3 to ComP1Y' in the attached inspection report moat be <br /> 1 g 0 c os of receipt of this ixrspe�-don. Vis,Gem fication form must besubmitted to th <br /> Envm)nm.ental Health bcPartmeAt 011)) address at the top of this farm Within s b s b i e e <br /> inspection report. Y receipt of the <br /> All c ections to oth r vi lati ns nuttd in the attached Inspect Report(TR)or Ccitinuatioi�Fo <br /> disputes to gray violations,are to be submitted using this certi$catiou and returned to EfLO ForW,or <br /> unless otherwise. in the 1R, 60 da. <br /> For tllS Ceffificatlon t0 be Complete the operator of the site <br /> luust <br /> include. <br /> • A.statement documenting what uxTeetive actioxls Ivere taken oz will betakenfor each violation <br /> • copies of sample results/nuaiife s/training records/other appropriate <br /> verifying correctionspamwork,and/or photos <br /> • Operator's certification <br /> ................. <br /> TnsPCCtion Date:_ s3 � 1n.Tected 1�y: M <br /> Facility Address: EPA ID#: <br /> 1 certify tinder penalty of law that: <br /> 1, T have corrected the Violations specified,in the Inspection Report from the abolre-mMtioxied <br /> inspmtion date. <br /> 2. Z have personally exatnined the following doaunentatiou submitted m proof of compliance FOR <br /> )EACH VIOLATION and I believe the information to be true, accurate, and complete: <br /> Plwtos N/ Paperwork ✓ Statement <br /> 3. 1 am authnr zod to subnr t 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 Zinc and/or imprisonmenr for known.violations. (HSC 25191) <br /> Name: .f ivs?t g- C.H 0 D A Title: vie- <br /> J l� <br /> I <br /> signature: � <br /> E1D 22-02-005 Rev 12-04 <br />