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SAN JOAQUN COUNTY__ �('-1 ENviRONM13 <br /> DEP <br /> 600 East Man Street,uTALHEALTH Stoddon,CA59 20 -3029 M . <br /> l Telephone:(209)468-3420 Farr:(209)468-3433 Web:www.siaov.adehd RECEIVED <br /> RETURN TO COMPLIANCE CERTIFICATION NOV 06 2013 <br /> ENVIRONMENTAL HEALTH <br /> Any MINOR violations noted in the'Notice to Comply°in the attached Inspection Report muOMMIT/SERVICES <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 30 days of receipt of the <br /> Inspection Report. HSC 25404.12(c)(1) <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. HSC 25185(c)(3) <br /> Note: All EHD staff time associated with failing to comply by the above noted dates will be <br /> billed at the current hourly rate. <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: 1 b/l -7/ t3 Inspected By:Stacy Rivera <br /> Facility Address: l l 37 S • S-�UC cS& EPA ID/f <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. 1 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_ 1 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 25191) <br /> Name: t l Title: aer4s7vniL <br /> Signature: T::�) Date: \\ p 1 <br /> EHD 71-02-005 Rev 09/11 <br />