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SAN -JOAQUIN <br /> Environmental Health Department <br /> vim..•: �sfi'G`�riC"fs �rO+rS �Crr. <br /> RETURN TO COMPLIANCE CERTIFICATION <br /> Any MINOFR violations noted in tm -Notice to Comply'in the attached lnspecllon Report must tra nprrecked kt+in 3{I 411 <br /> receipt of this inspection. This certification farm must be submitted to the Environmental Fteatkh Department(Ebbs address at <br /> the bottom of This form within 30 days of racalpi of the Inspection Report. HSC 2W4-1.2(c)(1) <br /> All corrections to other ref 14alionss mated In the attached Inspeckiurl Report(Ire) or Continuation Form. yr disputes to arty <br /> violations, are to lie submitted using lhis certificattarj an(3 returned to EHO within 30 days unless otherwise specified In the <br /> In9pection Report. KSC 251$5fr-)(3) <br /> Note. All EHD staff t(rne associated with failing to comply by the above noted dates will be <br /> billed at the current hourly rate_ <br /> i <br /> For th is certifi Gat 0n to be cc)mplete, the operator of the site must include. <br /> A saatement documenting what corrective actions were taken or will be taken for each violation <br /> Copies of sample resultsfm2nifestsltralning recordsfother appropriate paperwork• andlor photos vartfying corrections <br /> - Operator's Gertlf1G`atian <br />+ inspection Date: 1 Inspected By: 41� <br /> I <br /> Facility Address: FRS ID: <br /> fI cerlify under penalty of law that: <br /> l <br /> 7. I have corrected the vlolat€ors Spenif"M in the Inspection Report from the aboyf,-menftned inspection date. <br /> i <br /> 2- 1 have personally examined the following daCUmentafion SUbmittt?d 8$ proof of compliance FOR EACH Vt0LATION <br /> and 1 believe the information to be true, accurate,and complete. <br /> PhctasPaperwork/ Statement <br /> 3. 1 afn authorized to submit this Certification on behalf of the Respondent. <br /> 4. 1 am aware that there are signiricant penalties for submitt,ng false information, including the possibility of a fine andlor <br /> Imprison nt for known violations. (HSC 25191) <br /> Name: Title: , — <br /> signature-.- <br /> Date: 1 01 l <br /> tL) (FYI G� (rr� 0"Y-n 41LI) t r -� <br />