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SAN JOAQUlk BOUNTY <br /> ENVIRONMENTAL HiEwhi DEPARTM <br /> 600 East Main Street, Stenon,CA 95202-3029 <br /> Telephone:(209)468-3420 Fax.(2O)488-3433 Web:www.s' oda v.or%q ehd <br /> RETURN TO �x <br /> E 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 inspection. This certification form must be submitted to the <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 (IR) or Continuation Form, or <br /> disputes to any violations, are to be submitted using this certification and returned to EHD within 30 dans <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 t the current hourly rate o 1 ( e inning 8/1/09 the hourly rate will be$115). <br /> C this ii ti to be C the operator of the site must include: <br /> • A statement documenting what corrective actions Were taken or will be taken for each violation <br /> • Copies of sample results/manifests/training recordsiother appropriate paperwork, and/or photos <br /> verifying corrections <br /> • Operator's certification <br /> Inspection ate: / Inspected By:._ W,!,L Le <br /> Facility res : j '1 <br /> I certify under penalty of law that: <br /> 1. 1 have corrected the violations specified in the inspection Report from the above-mentioned <br /> inspection date. <br /> 2. 1 have personally examined the following d6bUhlentation submitted as proof of compliance FOR <br /> EACH VIOLATION and I believe the information to be true, accurate, and complete: <br /> Photos Paperwork fliatement <br /> 3. 1 am authorized to submit this certification on 6half of the Respondent. <br /> 4. 1 am aware that there are significant penalties f submitting false information, including the <br /> possibility of a fine and/or imprisonment for known violations. (HSC 25191) <br /> Name: ® Title: <br /> Signature: Date: 4aZoo 167,2 <br /> EHD 22-02-005 Rev 06/09 <br />