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SAN JOAQUIN COUWY <br /> ENVIRONMtNTAL HEALTH DEPARTMENT <br /> 1888 East Hazelton;Aven ;atocktori,California 952, 05-,6232 <br /> e#ephone:(209)468-3420 Fax,(109)4910-3433 Webs:www.sioovoro1ehd <br /> ,ETURN TO COMPLIANCE CERTIFICATION <br /> Any I, NQf violatioris noted in the"Notice to Comply"ire the attached inspection Report must be <br /> corrected within 30 Jav§of receipt of this inspection. This certification farm must be submitted to the <br /> Environmental Heal h.Department(EHL)address at the top of this farm within 30 days of receipt of the <br /> Inspection Report. ISC 25404,1.2(c)(1) <br /> All corrections to otl ier violatiou§noted in the attached Inspection Report(IR)or Continuation Form,or <br /> disputes to any violations, are to be su mitte l u0rag this certification and returned to S C Within 3,00idays <br /> unless otherwise sdfied in the Inspection Report. 'HSC 25185(4)(3) <br /> Nate: All EHD st ff time associated with falling to comply by the above netted:dates gill be <br /> billed at tlZ a current hourly rate <br /> For this cert fication to be complete.,the operator of the site must Indgde: <br /> A statement dc cumenting what corrective actions were taken s or will be taken for each violation <br /> * Copies of saml 4e results/manifests/training eecordslpther appropriate paperwork, and/or lahotos <br /> verifying corre tions k <br /> • Operator's cerlification <br /> Inspection Date: - Inspected By Ar`t d pi <br /> Facility Address: � K � EPA I <br /> I certify udder penalty of law tha : <br /> 1. 1 have corrected the violations'specifi d ln,t0e,Inspection Report from the above-mentioned I <br /> inspection c ate. <br /> 2. 1 have personally examined the folio ng dpsum r#tabon submitted as proof of compliance FOR <br /> EACH VIOL ATI ON and I believe the inform,aition " e true, accurate,and complete: <br /> PhotosPaperwork ` tateert <br /> 3. 1 am authorized;to submit this certification on behalf of the Respondent.' <br /> 4. 1 am aware that there are significant p ri lti s for 'bmltting false information, including the <br /> possibility of a fine and/or imprisonmfor know violations. (HSC 25191) <br /> t <br /> _Narr�e; � ' Title:, <br /> Signatu Cute, <br /> EHO 22-U-005 Rev 04M 9112 APR U 14 F <br /> ENVIRONMENTAL HEALTH <br /> DEPAPTMENfi' <br />