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SAN <br />COUNTY 0 <br />ENVIRONMEN=ZTH DEIARTMENT <br />75 C <br />600. East Main St!��t�, 13 A 95202-3029 <br />Telephone: (209) 468-3420 F��(�#408-3433 Web: www.sffiqov.orq/ehd <br />RETURN TO COMP�!ANCE CERTIFICATION <br />Any MINOR violations noted in the "Notice to Comply�' in the attached Inspection Report must be <br />corrected within 30 days of receipt of this insp6ctj6n�. <br />This certification form must be submitted to the <br />Environmental Health Department (EHD) address at thelop of this form within 30 days of receipt of the <br />Inspection Report. <br />All corrections to other violations noted in the attached Inspection Report (IR) or Continuation Form, or <br />disputes to any violations, are to be submitted using this certification and returned to EHD within 30 days <br />unless otherwise specified in the Inspection Report,. <br />Note: All EHD staff time associated wfaili• <br />to comply by the above noted dates will be <br />billed at the current hourly rate. <br />r— <br />For this certification to beCOMPIft the operator of the site must include: <br />• A statement documenting what corrective'a ns *ere taken or will be taken for each violation <br />• Copies of sample resultsftanifests/training� <br />9ros,,other appropriate paperwork, and/or photos <br />verifying corrections <br />• Operator's certification <br />LEZM37_••;� <br />I certify under penalty of law that: <br />Inspected By: <br />[W-1111 <br />1. 1 have corrected the violations specified in the inspection Report from the above-mentionei <br />inspection date. <br />2. 1 have personally examined the following documentation submitted as proof of compliance FOR <br />EACH VIOLATION and I believe the inf,•, Oration to be true, accurate, and complete: <br />Photos Paperwork 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 <br />possibility of a fine and/or imprisonment for known violations. (HSC 25191) <br />Name: Title: <br />am= <br />no <br />EHD 22-02-005 Rev 10/09 RETURN TO COMPLIANCE <br />