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02/03/2012 15:13 2098362 16 PAGE 06/06 <br />SAN JOAQUIN COUNTY <br />ENMp0NMFNTAI, HEALTH DEPARTMENT <br />600 East Main Stmet, SWJdOn, CA 95202-3029 <br />Telephone: (209) 468-3420 Fax_ (209) 4883433 web. nM:5lQM <br />RETURN TO COMPLIANCE CERTIFICATION <br />Any MINOR violations naffed in the "Notice to Comply- in the attached Inspection Report must be <br />corrected within 3Q da►►_s of recelpt of this inspection. This certification form must be submitted to the <br />ErMronmental Health Department (EHD) address at the top of this form within 34 days of receipt of the <br />Inspection Report, HSC 25404.1.2(c)(1) <br />AI[ corrections o*other viol ons nOteci in Me attached inspection Report (IR) or Continuation Form, or <br />dispputes to an viol�'o"ns, are to be submitted using this certification and returned to EHD within 30 dans <br />unless otherwise sppeeccfled In the Inspection Report. HSG 25185(c)(3) the above noted dates will 6e <br />Note: All EHD staff time associated VAth failing to comply by <br />billed at the current hourl rate. <br />For this certification to a completethe operator of the site must Include: <br />• A statement documenting what corrective actions were taken or will be taken for each violation <br />• GOW-S of sample resultslmanifests/training records/other appropriate paperwork, andlor photos <br />Inspection Date:_a�r �` inspected ByA - <br />Facility Address: l�t Lb ti. EPA ID*: <br />CA cisr6 <br />I certify under penalty of taw that: <br />1. 1 have corrected the violations specified in the Inspection Report from the above-mentioned <br />inspeMion date. <br />2. 1 have personally examined the following documentation submitted as proof of compliance FOR <br />EACH VIOLATION and I believe the information to be true, accurate, and complete: <br />Photos Paperwork__1S Statement <br />3. lam authorized to submit this c aftification on behalf of the Respondent. <br />4. 1 am aware that there are significant pend ties for submitting false information, including the <br />possibility of a fine and/or imprisonment for known violations. (HSC 25191) <br />Name: <br />1i <br />END 22 -ft -M5 RW 09M G��' �l� ► {�� <br />41 cequt'reid <br />Date: <br />+o co 41 o6 <br />�,n-F�rmak r1 <br />1P <br />ud (4k-N��ratUr <br />