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SAN IOAQUIN COUNTY • <br /> ENVIRONMENTAL HEALTH D CA 95202 3029sioov oralehd <br />1W <br /> 600 East Main Street, Sto 468 3433 Web <br /> WW <br /> -relephone: (209)468-3420 Fax: (209) <br /> COMPLIANCE CERTIFICATION <br /> RETURN TO <br /> in the attached Inspection Report must be <br /> in of this form within 30 days of receipt of the <br /> Any MI�R. iIviolations0 dans ofdrece pt of thisensp Comply" <br /> to inspection. This certification form must be submitted to e <br /> corrected w � address at the top <br /> Environmental Health Department (EHD) Report <br /> IR or Continuation Form, or <br /> Inspection Report. Inspection Rep (IR) <br /> violations, are to be submitted using this certification and returned to EHD within <br /> All corrections to other violations noted in the attached <br /> disputes to any <br /> unless otherwise specified a the Inspection Reportto comply by the above noted dates will be <br /> Note: All billed D staff <br /> o fcurrent hourly rate.associated failing <br /> tete the operator of the site must include: <br /> For this certification to be comp llb paperwork, and/or vi photos <br /> . A statement documenting what corrective actions were taken or will be taken for each violation <br /> . Copies of sample resultslmanifests/training recordslother appropriate <br /> verifying corrections <br /> Operator's certification <br /> Inspected By: <br /> Inspection Date:_ <br /> EPA IDS: <br /> Facility Address: <br /> I certify under penalty of law that: <br /> �. I have corrected the violations specified in the Insp ct m RE':" L. <br /> inspection date. <br /> ned <br /> the <br /> ollowing <br /> 2 EACH VIOLATIIONXa dl I believe the nformation t� etruea <br /> s. cct as proof of compliance FOR <br /> Iraateand complete: <br /> Photos Paperwork <br /> Statement <br /> 3. 1 am authorized to submit this certification on behalf of Y-e ResPondent- <br /> 4. 1 am aware that there are significant penalties for subryUrl: -, <br /> possibility of a fine and/or impriisonmerd for known violion y Inf o <br /> Name: <br /> it <br /> S►9nature TJ1 <br /> EHO <br /> z2-pappsgev hips <br />