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0 SAN JOAQUIN COUNTY 0 <br />ExvrRoNmE TALHEALTHDEPARTMEW <br />344 East Webtr AYtan, 3' Flom. SbxUm CA 452032-2708 <br />T'thphoxe: M) 4683420 FRS (2W) 46&3433 W& WW'W41LQvLtttElCW <br />RETURN TO COMPLIANCE CERTIFICATION <br />Any bOLOR violations noted in tate "Notice to Comply" in the attached inspection report must be <br />corrected within 301 days of receipt of this inspection. This certification form trust be submitted to the <br />Environmental Health went (EHD) address at the top of this form within 35 clays of receipt of the <br />inspection report. <br />All corrections to other violations noted in the attached Itupection Rq*rt (IR) or Continuation FormE, or <br />disputes to any violatiotjs .are to be submitted using this certification and returned to ERD v-d1biln 60 clay <br />unless otherA ise specified in the IR. <br />F.or this certification t4 be COMPIde, the operator of the sits must include: <br /># A statement documenting what corrective actions were taken or will betaken for each violation <br />o Copies of sample results/manifests/training, recc3Wother appmptiate paperwork, aadlor photos <br />verifying corrections. <br />• Operator's coniftcation <br />Inspection nate: i- 2 013 Inspected By: <br />Facility Address:r �� 5 L� N� i� o�c: �•�EPA Wk <br />I certify under penalty of law that: <br />L I have corrected the violations specified in the Inspection Report from the above-mentioned <br />inspection date. <br />2. 1. have personally examiried the following documentation submitted as proof of compliance FQR <br />EACH VIOLATION and I believe the information to be true, accurate, and complete: <br />Photos Paperwork Statement <br />3. 1 am authorized to submit this certification onbehalfofthe Respondeat_ <br />4. t am aware that there arc significant penalties far submitting false information, including the <br />possibility of a fine anchor imprisonment for known violations. (HSC z5 191) <br />Name: CASL- Title: Puw��, <br />Signature: /Xl - <br />SAN <br />EHD 22-012-005 Rcv <br />Date: /-/- Z) - 2-6 13 <br />w EE K o -f 7-3,.: <br />