COMPLIANCE INFO_PRE 2019 - Laserfiche WebLink

Home Browse Search

Dec 04' 09 11 : 19a S & J ^adiator 209-83r 2011 p. 2 RETURN TO COMPLIANCE CERTIFICATION Any MINOR violations noted in the "Notice to Comply" in the attached Inspection Report must be corrected within 30 days of receipt of this inspection. This certification form must be submitted to the Environmental Health Department (EHD) address at the top of this form within 30 days of receipt of the Inspection Report. All corrections to other v olations noted in the attached Inspection Report (IR) or Continuation Form, or disputes to any violation , are to be submitted using this certification and returned to EHD within 30 days unless otherwise specifie=d in the Inspection Report. Note: All EHD staff time associated with failing to comply by the above noted dates will be billed at the current hourly rate of$105 (beginning 811109 the hourly rate will be $115). For this Certific tion t0 be Complete the operator of the site must include: • A statement documenting what corrective actions were taken or will be taken for each violation • Copies of sampler sults/manifests/training records/other appropriate paperwork, and/or photos verifying correction • Operator's certifica ion Inspection Date: VA Inspected By:_� �cl Facility Address: '`L SIC ��t' EPA ID#:CA -- (-;`51 I certify under penalty of law that: 1. 1 have corrected the violations specified in the Inspection Report from the above-mentioned inspection date. 2. 1 have personally examined the following documentation submitted as proof of compliance FOR EACH VIOLATION and I believe the information to be true, accurate, and complete: Photos x Paperwork X_Statement 3. 1 am authorized to submit this certification on behalf of the Respondent. 4. 1 am aware that there are significant penalties for submitting false information, including the possibility of a fine and/or imprisonment for known violations. (HSC 25191) Name: E c1 C�l>' �,(��Cts 1 CL Title: 1w hc r Signature: Date: EHD 22-02-005 Rev 06109 State of CaliforniaCalifornia Envirc nmentat Protection Agency Department of Toxic Substances Control-GISS P.O.Box 806,Sacramento,CA 95612-0805 Reset Form Print CALIFORNIAHAZARDOUS WASTE PERMANENT ID NUMBER APPLICATION Please type or neatty print in ink. Please review the line-by-line instructions carefully. To a eck on the status of your request,go to www.hwts-disc ca. ov and click on Reports. NEW NUMBER REQUESTS Check all that apply. (See instructions.) N. - - - —-__... irl ne n ha7arr1n11c WASte. n Generator i—ITransport.er