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JUN-08-2007 15.27 P.02 <br /> E SAV JOAQUIN COONT Y <br /> $NVlitoNmENTAL HEALTH DEPARTMENT <br /> 600 East Main Surat,Stockan,CA 95202.3029 <br /> i Telephone:(209)468-3420 Fax:(209)468-3433 Web:ww�jxuv.orp_/ehd <br /> RETURN TO COMPLIANCE CERTIFICATION <br /> _. A0 MMOR violations noted in the"Notice to Comply"in the attached inspection report must be <br /> • . ' *ithin 30 days of receipt of this inspection. This certification form must be submitted to the <br /> Earonmental Health Department(EHD)address at the top of this form within 35 days of receipt of the <br /> �cfion report <br /> All ' •rre h us to other vielati=noted in the attached Inspection Report(IR)or Continuation Form,or <br /> Idi ` to any violiations,are to be submitted using this certification and returned to IHD with <br /> 60 days <br /> otherwise specified in the IR <br /> r <br /> . .F this Certification t0 be completethe operator of the site must include: <br /> S �) <br /> fig A statement documenting what corrective actions were taken or will be taken for each violation <br /> Copies of wmple results/manifests/training records/other appropriate paperwork,and/or photos <br /> vexifyiug corrections <br /> s Operator's certification <br /> p <br /> Ia flan Date: Nd Q O Inspected By: <br /> •J <br /> : lity Address �� 3 tom_ �1 due ctd c�,Si1[n,°� EPA ID#: <br /> r certify under penalty of law that: <br /> i i I have eorr&aed the violations specified in the Inspection Report from the above-mentioned <br /> f inspection date. <br /> :1 I haws personally examined the following documentation submitted as proof of compliance FOR <br /> 11. EACH VIOLATION and I believe the information to be true, accurate, and complete: <br /> f Photos � a erwork Statement <br /> I p _. <br /> ? 1 am authorized to submit this certification on behalf of the Respondent. <br /> . Yam aware that there are significant penalties for submitting false information, including the <br /> possibility of a fine and/or irnprisomnent for known violations.(HSC 2519 1) <br /> ame: 51����U�(10/nar�(_\\e\ Title: <br /> ignature: - _ Date: ,TQP 2(b7 <br /> - y <br /> EHR <br /> •:22-02-045 Rei►05/07 <br /> :i <br /> TOTAL P.02 <br />