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SAS'JOAQUna COM—Tl' <br /> EhTviRohMENTALHF_ALT i DEPARTMENT <br /> 600 East Main Street,Stochon,CA 95302-3029 <br /> Telephone:,(209)468=3420_Fgx:(209)-468 -433 Web:unvrw.sigov.org/ehd <br /> RETURN TO COMPL�TC CERTIFICATION <br /> Any III flR adolalions;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 farm must be submitted to the <br /> Environmental i-Iealth Department(EM) address at the top of this form within 35.days of receipt of the <br /> inspection report. <br /> All corrections to other violations noted in the attached Inspection Report JR)or Continuation Form,or <br /> disputes to-any violations, are to be submitted using this certification and returned to EHD within 60-days <br /> unless otherwise specified in the IR. <br /> f <br /> For this certification to be Complete 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/toning records/ogler appropriate paperwork,and/or photos <br /> ver ring corrections. <br /> s Operator's certification <br /> Inspection Date Inspected By: <br /> Facility Address: EPA ID#: <br /> I certify under penalty of law that: <br /> 1. I have corrected the violations specified in the Inspection Report from the above-mentioned <br /> inspection date. <br /> 2. I have personally 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 /> Photos Paperwork Statement <br /> 3. I am authorized to submit this certification on behalf 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 2519 1) <br /> Naive: Title:, <br /> Signature: Date: <br /> EHD 22-02-005 Rev 05/07 <br />