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SAN: J,o A46IN 6UNTY ENVIRONMEN AL I f, H`kLfH DEPARTMENT 0, 600 East Main Street; M66-ko6 CA 95202-3029 Telephone: (209) 468-3420 6: (2bO) 468-3433 Web: www.siaov.org/ehd RETURN TO COMPLIAN6E CERTIFICATION Anv MINOR violations noted in the "Notice to lt�6�1 thattached Inspection Report must be corrected within 30 days of receipt of this in certification form must be submitted to the lsp�ct Environmental Health Department (EHD) addria he top of -this form within 30 days of receipt of the Inspection Report. All corrections to other violations noted in the attackoi6il4pection Report - (IR) or Continuation Form, or disputes to any violations, are to be submitted U911irigthii bleftification and- returned to EHD within 30 days unless -otherwise specified in the Inspection Report. Note: All EHD staff time associated with Wilrij to �omply by the above noted dates will be billed at the current hourly rate. For this certification to be co�416W the operator of the site must include: • A statement documenting what corrective actions, � 4,�rd taken or will be taken for each violation • Copies of sample results/manifests/training rkordAther appropriate paperwork, and/or photos verifying corrections • Operator's certification Inspection Date: Facility Address: I certify under penalty of law that: 1. 1 have corrected the violations specified In't1i 6 I'nis'pection Report from the above-mentioned inspection date. 2. 1 have personally examined the following d0660niritbition submitted as proof of compliance FOR EACH VIOLATION and I believe the inf6r iMation to be true, accurate, and complete: Photos .. OaprWork Statement 3. 1 am authorized to submit this certification on behalf of the Respondent. 4. lam aware that there are significant penalties fob 6uibmitting false information, including the possibility of a fine and/or imprisonment for known Violations. (HSC 25191) Name:— EHD 22-02-005 Rev 10/09