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002454 COUNTY <br /> AN JOAQUIRECEIVED <br /> - - - --- --- ._ _ - _.. . .SIV - -� <br /> - - <br /> ENVIRONMENTALHEALTH bE�A TNdENT <br /> ,nun w,600„EaNV ain Street Stockfon CRS 9M2-3029 �( ? <br /> Tele: �2�9j arc( Q :www.s gov.or-q/ehd 2011 <br /> > .:. <br /> Lrilll't���I'.19l� <br /> ENVIRONMENTAL HEALTH <br /> [T/SERVICES <br /> �' RN TO COMPLIANCE-CERTIFICATION <br /> Any MINOR violations note in the "Notice to Comply" in the attached Inspection Report must be <br /> corrected within 30 days of receipt of this inspection. This certification form must be submitted to the <br /> Environmental Health Dep i-tment (EHD) address at the top of this form within 30 days of receipt of the <br /> Inspection.Re or <br /> Dian-o+cAGhs <br /> All corrections to other viol tions noted in the attached Inspection Report (Ifs: or Continuation Form, or <br /> disputes to any violations- re to be submitted using this certification and returned to EHD within 30 days <br /> unless otherwise specified i the Inspection Report. <br /> Note: All EHD staff tim associated with failing to comply by the above noted dates will be <br /> billed at the Curr nt hourly rate. <br /> For this certlficat on t0 be complete the operator of the site must include: (a <br /> •�A statement document ng what correc Ive actions were taken or wihl be taken for each violation <br /> • Copies of sample resu stmanifests/training records/other appropriate paperwork, and/or photos <br /> verifying corrections <br /> t <br /> T. rator's certificair "MM M1111171111; <br /> , .an •.. .. <br /> • 0 <br /> Oe <br /> Inspection Date:Se• %�3 jo�_2 Inspected By: <br /> �,/L% J Cljf :/'D ��> �,�11 EPA ID#: <br /> Facility-Address:J <br /> It4^L:`:11 <br /> I certify under penalty,o ,law.that; <br /> 1-- 1 have corrected the violations specified in the Inspection Report from the above-mentioned <br /> m2 inspection date <br /> 2. I have personally ex mined the following documentation submitted as proof of compliance FOR <br /> EACH VIOLATION nd I believe the information to be true, accurate, and complete: <br /> Photos Paperwgrk _Statement <br /> 3. 1 am authorized to s bmit this certification on behalf of the Respondent. <br /> 4 1 am aware that ther are significant penalties for submitting false information, including the <br /> possibility of a fine a d/or imprisonmentfor known violations. (HSC 25191) <br /> Name- it x4i Title: <br /> Signature . > Date Q— /�-- <br /> EHD 22-02-005 Rev 08/08 <br />