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- -�� •••�Lu•, rIuui, atocxton, UA 95202-2708 <br /> :4Q Telephono 1209)468-3420 Fax:(209)468-3433 Web.wv ov.or ehd <br /> RETURN TO COMPLIANCE CERTIFICATION <br /> I1,• �. Y <br /> .,�..-A Any MINOR violations noted in the"Notice to Comply" in t t e�l1insec ion report must be <br /> corrected within 30 days of receipt of this inspection. This eertification,forrnZ mttl�t� <br /> iii submitted to the <br /> ?� Environmental Health Department (EHD) address at the to of ,h <br /> P #� 44mri Wi> ys 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 /> J%.. 'L disputes to any violations, are to be submitted using this certification and returned to EHD 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 /> ` :'S • 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/orp hotos <br /> verifying corrections <br /> a. • Operator's certification <br /> `rtu <br /> Inspection Date: j Inspected By: Ms �� V A t <br /> ' Facility Address: ? o-o rri � EPA ID#: CA44-0 M'%-- <br /> 1 <br /> certify under penalty of law that: <br /> l. I have corrected the violatio�]�s specified in he Inspe ion eport the above-mentioned <br /> inspection date. <br /> 40 <br /> r.: <br /> 2. I have pers ally examined th following docu entation submitted as proof of compliance FOR <br /> EACH ORATION and belle nformation to b true, accurate, and m l te: <br /> at./,C,�,�, <br /> :•sj�'I <br /> 4? Photos Paperwork Statement WK4R-� <br /> `Ike <br /> 3. I am authorized to submit t is certification on behalf of the Respondent. <br /> n <br /> 4. I am aware that there are significant penalties for submitting false information, including the <br /> { possibility of a e impri nment for known v• Iations. (HSC 21. ) <br /> - o <br /> Name: ' C-n Lff Title: <br /> Signature: Date: 3 o <br /> 4-0 <br /> n: y�( 44 <br /> C u <br /> J <br /> EHD 22-02-005 Rev 12-04 <br /> 1 � M <br />