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SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT '7bjjtNb O <br />600 East Main Street, <br />029 <br />Telephone: (209) 468-3420 Fax: (209) 468-3 33 Web: www si oovv.org/ehd �LNn � Inov N3 S <br />RETURN TO COMPLIANCE CERTIFI <br />R' 1. .,. �7V <br />Any MINOR violations noted in the "Notice to Comply" in the attached Inspection Report mus"f°bi ,,P „ <br />corrected within 30 days of receipt of this inspection. This certification form must be submitted to the <br />Environmental Health Department (EHD) 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 (IR) or Continuation Form, or <br />disputes to any violations, are to be submitted using this certification and returned to EHD within 30 days <br />unless otherwise specified in the Inspection Report. <br />Note: All EHD staff time associated with failing to comply by the above noted dates will be billed at <br />the current hourly rate ($122). <br />For this certification t0 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/training records/other appropriate paperwork, and/or photos <br />verifying corrections <br />• Operator's certification <br />Inspection Date: S 27 —Inspected By: l <br />Facility Address: 1(o l I S, 4yW rrW44 1/ EPA ID#: C/41, 00027_S yd0 <br />S j oc_&-.-b^/ (.4 ' <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 t/ Statement <br />3. I am authorized to submit this certification on behalf of the Respondent. <br />4. 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 />�L S o W Title: r. F. 5 <br />Date: ) Z --`l <br />EHD 22-02=005 Rev 08/10 <br />