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AN JOACUIN COUNTY <br />ENVIFicNIVILIN I AL HLALIFIDEPARTMENT <br />5UU EMI Main Etrcct, Etocirtnn, [I5AT-30PD <br />Telepholith2 (209) 4GB-0420 Fax: (2(A) 4M2-342.3 Web; uvww.sitx..v .ort- ils-k I <br />RETURN TO OMPLIANCE CERTIFICATION <br />Any MINOR violations noted in the "Noti <br />gglrected within 30 dav§, of receipt of thi <br />Environmental Health Department (EHD <br />Inspection Report HSC 25404.1.2(c)(1) <br />All corrections to other violations noted i <br />disputes to any violations, are to be sub <br />unless otherwise specified in the Inspect <br />Note: All EHD staff time associate <br />billed at the current hourly r <br />e to Comply" in the attached Inspection Report must be <br />inspection. This certification form must be submitted to the <br />address at the top of this form within 30 days of receipt of the <br />the attached Inspection Report (IA) or Continuation Form, or <br />Itted using this certification and returned to EHD within 30 days. <br />on Report. HSC 251B5(c)(3) <br />with failing to comply by the above noted dates will be <br />te. <br />For this certification to b complete the operator of the site must include: <br />A statement documenting what corr olive actions wer taken or will be taken for each violation <br />Copies of sample results/manifeststre.ining records/other er appropdate paperwork, and/or photos <br />verifying corrections <br />Operators certification <br />Inspection Date: 3I1D.Iaova_ <br />4303 $. Miley A. <br />Facility Address: 5 <br />I certify under penalty of law that: <br />1. I have corrected the violations s <br />inspection date. <br />nspected Roi:..c.v-t- i_o z. <br />PA ID#: JVA <br />ecified in the Inspection Report from the above-mentioned <br />2. I have personally examined the fpllowing documentation submitted as proof of compliance FOR <br />EACH VIOLATION and I believe the information to be true, accurate, and complete: <br /> <br />Photos X Paperwork X Statement <br /> <br />I am authorized to submit this certification on behalf of the Respondent. <br />I 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 25191) <br />Title: ...Rc au I et 4-0i-i kkinekiteir Name' t41 e-letete. I 14455Y-A,Iia <br />Date: VIA.4.4, Vergaa_. <br />-HI ) 114)2.005 Rev 9/11 <br />d ZtrOZKZ6OZ UOPIOOI3 wego ciseq d 0 :0 -le tiv