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SACS 41116�661k6U TY 0 <br />ENVIRONMElS"ALHE4LtH DEPARTMENT <br />600 East Main §treet­SitOc6,n, CA 95202-3029 <br />Telephone: (209) 468-3420 � i: ( 69) 468-3433 Web:www.siaov.org/ehd <br />RETURN TO COMOUANCE CERTIFICATION <br />Any MINOR violations noted in the "Notice to jh­� the attached Inspection Report must be <br />corrected within 30 days of receipt of this inspkii6h. -this certification form must be submitted to the <br />r f <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 Ihsoection Report (IR) or Continuation Form, or <br />disputes to any violations, are to be submitted, dsirid' thii cei rtification and returned to EHD within 30 days, <br />unless otherwise specified in the Inspection Report. <br />Note: All EHD staff time associated with M1111166; to comply by the above noted dates will be <br />billed at the current hourly rate. <br />For this certification to be corhOlet the operator of the site must include: <br />• A statement documenting what corrective actions wire taken or will be taken for each violation <br />• Copies of sample results/manifests/trainir g recbrd§iother appropriate paperwork, and/or photos <br />verifying corrections <br />• Operator's certification <br />Inspection Date: Inspected By: <br />Facility Address: EPA ID#: <br />1. 1 have corrected the violations specified in the' Insi pektion Report from the above-mentioned <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 iriforma"fidn to be true, accurate, and complete: <br />7�lhotos 066orwork Statemel <br />3. lam authorized to submit this certification on be half 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 />EHD 22-02-005 Rev 10/09 RETURN TO COMPLIANCE <br />