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U i SAN.I A. COUNTY <br /> ENVIRONMEWAL HFALTH DEPARTMENT <br /> 600 <br /> E.Main St.,SP {Cion,CA 95202-3029 <br /> Te&pk6j,,,(209)468.3420 Fax:(209)468-3433 Web.'MBWXW–V—.0MA(f--b—d <br /> RETURN TO CONTIJANCE CERTIFICATION <br /> Any MWOR viol afiow no in the A'Ndtice to COMIY'® the attached Inspection Report must be <br /> 9M tedM— 3 0 rm must bsubm;itted to the <br /> gU& 4M of=cipt of this inspe4don. TWS oe cerfification.f <br /> Envijonmentgl lievith D QBHD)address at the top of this form vd35 days of mccipt of the <br /> Inspection Repoit <br /> All pmMtLijonR W_Qg=_viol aaons no in the anached Inspection Report or Coat tinuatilOn Form,Or <br /> disputes to any violations,are to be submitted using this certification and returned to EHD-Md�3 �da <br /> unless othmvise specified in the Inspection Report. <br /> Note- AD ERD staff time associated wilh faging to comply by the above not dates w1H be billed at <br /> the current our rate <br /> For this certifleation to be completethe operater of the site must include- <br /> s A statement documenting what corrective actions were taken or will be taken for each violation <br /> a Copies of sampler esultstm&uifests/iTainingrecords/other appropriate paperwork,and/or photos <br /> verifying corrections <br /> a Operator's certification <br /> In"otion Date: Inspected By:���� <br /> Facility Address: 'I L) �Vv-Ck(--� �3 EPA.!D#: - C�-�e C',M l 2-1 <br /> I cerfify under penalty of law that: <br /> 3. 1 have corrc=d the violations specified in the Inspection Report from the abov�mentioned <br /> inspection date. <br /> 1 1 have persanally examined the following documentation submitted as proof of compliance FOR <br /> EACH VIOLATION and I believe the information to be true,accurate,and complete: <br /> Photm 'Y' rk Statement <br /> 1 1 am authorized to submit fl3is certification an behalf of the Respondent. <br /> 4. 1 mn-aware that them am significant penalties for mibmitting false ifformation,including The <br /> p bility of a fine and/or ioment for im violations.(HSC 25191) <br /> .oss, own <br /> Nmme: Title; <br /> r <br /> Sign re. Date- 31 I(i� <br /> FHD 2202-005 Rev 08/10 <br />