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SAN JOAQUIN COUNTY <br />HEAL11-i-i DEPARTME <br />I k <br />to <br />ENVIRONM <br />600 pasty# Street, SlocMon, CA 95202-:3 29 v D lel-�n; cp <br />.gjqL <br />Telephone.- (2091468-3420 Fax: (209.) 468-3433 Web: ww <br />ENVIRONTOENT HEALTH <br />RETURN TO COMPLIANCE CERTIFICATMTSERVICES <br />Any LvIINOR violations noted in the "Notice 'Co Comply" in the attached inspection Report must be <br />corrected within 30 of receipt of this inspection. This certification form must be submitted to the <br />Ldays <br />Environmental Health Department (EHD) address at the top 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 ((R) 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 with failing to comply by the above noted dates will be <br />billed at the current hourly rate of $105 (beginning 8/1/09 the hourly rate will be $115). <br />For this certification to be completethe operator of the site must include: <br />* A statement documenting what corrective actions were 'Laken or will be taken for each violation <br />* Clopies of sample results/manifests/training records/other appropriate paperwork, and/or photos <br />verifying corrections <br />* Operator's certification <br />Inspection Date- Inspected By:_ -",.- <br />Facility Address,_ Z;Q EPA 1D#- <br />S-ru C, C, S- <br />I certify under penalty of law that: <br />1. l have corrected the violations specified in the inspection Report from the above-mentioned <br />inspection date. <br />Z 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 compiete: <br />Photos —Paperwork -,Statement <br />1 lam 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: <br />Simature: <br />EN® 22-02-005 Rev 06109 <br />Date, <br />