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San Joaquin County <br /> E a*of rr►esrllYall fileaifth Departmard <br /> 'its Ea5l llilaunE�kn Aro9e i ue„S# v.,C4VvrvAat95205- 2 <br /> hTeiphaner kMg� 43420 Fair:;M 455-343.3 We&motvvn-saw,aami'e<i d <br /> RIMETURN TO COMPLIANCE CERTIFICATION <br /> Any KNOR Votatiorhs noted in the'Nolice to Corr pW in the attached tin Repod rnusl be correded mAtt in 30 days of <br /> receipt of this inspection. TW certifhcabon form must to submitted to the Environmental Health Department(EHD)address. <br /> the lop of tihls form vrithin30 days of receipt of the Ir>specion Report. HSBC 25404.1.2(c)(1) <br /> All corrections to other violations noted in Rhe attached Inspection Report(lit)or Continuation Form,or disputes to any <br /> violations, are to be submitted using this certification and returned to EHiDwithin 30 days unless otherwise specified in the <br /> Inspection.Report. HSC 25185(e)(3) <br /> Note: All EHD staff time associated with failing to comply by the above noted dates will be <br /> billed at the current hourly rate. <br /> For this certification to be complete, the operator of the site must include: <br /> A statement documenting what corrective actions were taken or will be taken for each violation j <br /> Copies of sample results/manifests/training records/other appropriate paperwork, and/or photos verifying correction! <br /> Inspection Date: !V(3yE.'ntooi "i ), ;'0 i`'i Inspected By: /�i;i`7 �/f l r)`3t:1 <br /> Facility Address: X3`00 i_. iA)LI'' 1, V!";f RD ('I.i:i�/ii_td l" � EPA ID: <br /> I certify under penalty of law that: <br /> 1. 1 have corrected the violations specified in the Inspection Report from the above-mentioned inspection date. <br /> 2. 1 have personally examined the following documentation submitted as proof of compliance FOR EACH VIOLATION <br /> I believe the information to be true, accurate,and complete: <br /> X Photos X Paperwork X Statement <br /> 3. 1 am authorized to submit this certification on behalf of the Respondent. <br /> 4. 1 am aware that there are significant penalties for submitting false information, including the possibility of a fine and/ <br /> imprisonment for known violations. (HSC 25191) <br /> Name: Greg Buncab Title: Senior Env. Health & Safety Specialist <br /> Signature: C Date. 12/14/2015 <br /> V t <br /> DEC 14 <br /> 2015 <br /> -NIVIRONM N"" l <br /> I.1'_".1 TW pCDP C-rA d"1'i <br />