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� 1 <br /> ^SAN',J:t AQ. 1'COk1NTY <br /> PV�1tRdlA!ti tN.AL4149.A�T DEPARTKNT <br /> 6W-ta.MC.Maiili.�gtser t ,Simon;•CA:982(Y -3029 <br /> Felephonet..f209)4f -3 2fl t '( es)` -1'33 Web:W":slooy.orc{/eratl <br /> RETURN TO COMPUANCE CERTIFICATION <br /> Any,M <br /> &NR vi(i Xtions.noted in the'Notice to Cofmpty" irt••tho ottached Inspection Report most be <br /> rc rr dty�iEb r¢ sof receipt,of tW4Jhspe.ati' 6 Thjs:, .bSrrwattan form.musr t-be submi�ftd to•the :• ;;°: <br /> t nh fr iftmental 1 keslth Department(Et l ) address,at•ttte-:t of this form within 30 days of.Mceipt of the <br /> Inspection Repi A. <br /> U corfectrons:I`:,i o or,ui0,atlons:.nat0d.1n'.the:att4chadjnspection:Repoft:(:t:R) or Continuat*-,Fgrr�, or. <br /> dtgp.uta5 tb ark kol tr6N5: afat6-bi Sub. . <br /> t :da qi i for •ari !'.r�?ttrrnec!to <br /> unfaa s (3� rW0 "�speariied.'irt.the"1 10ii.'• ; <br /> .. <br /> p <br /> Note: all EHE 1.stafftime associated--vWttr, #' ':to�admoly by the above note0i'dates vi�rtI:be' <br /> billed Ri'I:the current hourly rate. <br /> F'O( this c1;::rtti'jcation: tobe e Corr plot .the operator of the site must,inciude: <br /> • A staterner it documenting vahet apRe,>✓ii+Fle aqtions.were taken or will:be takecv.fvr:ea E viejation <br /> .: Copies of ; ;ample results/r ariife5ts/teaih'irtg reit ids/ ttaer-a rbpriatte:paperwork,..anot r photos. <br /> uejifying ci ,rrections I <br /> • Operator`s, ,ertification <br /> /_' c (topectodBy, .GY TOS— <br /> F�a # r:i4ll Imo: • :, t ;� 4,L .° °; <br /> I certify uni: :r penalty of law that: <br /> 1. I have i,orrected the violations specified in the tnspection Report from the above-rtentioned <br /> inspecti:m date. <br /> 2. 1'have l: , rsonaflyexar�red the fo' log,d tion subMitted.as,proof of coo- piia_rtoe-.F0h--%'.:: <br /> EACH V1OLATION and I believe the information to be true, accurate, and complete. <br /> Photos _Paperwork Statement <br /> 3., I am au hvrized to submit this.certifi Fror v;n b haff!49f.tt e;Respond.ent. <br /> 4. f am av�,tre:tl� t;there.ar'e..si r►xfrc t t s#ir; i itfist atse:iri¢brmati.Girry''i tiirtg:tl e. <br /> ossibi:l ly of a fine and/ter JSC 25491 <br /> ..r. <br /> 1416- Ch kleR <br /> Name MW <br /> rt ttfre r Date: <br /> EHD 22-02-005 Rev IG' !3 <br />