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05/20/2011 08:45 2097270859 GEORGE'S #1554 P. 002 /005 <br /> SAN JoAwri COUNT`' • <br /> L4WM0NMf Ni'AL HEALTH DEPARTHYE'NT <br /> 600 East Maim S&eeta Stoektoi4 CA 95202-3029 <br /> Telephone:(209)468-3420 Far;(209)468-3433 Web:w ww_s�gPyV MJZIO—d <br /> RETURN TO COMPLIANCE CERTIFICATION <br /> Any MINOR violations noted in the"Notice to Comply"in the attached.Inspection Report must be <br /> corrected wiihin.30 days of receipt of this inspection. 11is certification form must be submitted to the <br /> Finvironmental I health Department(EHD)address at the top of this form within 35 days of receipt of the <br /> Inspection Report. <br /> Alf corrections to other violations noted in the attached Inspection Report(IR)or Continuation Form,or <br /> disputes to�y violations,are to be submitted using this certification and.returned to EHD within 30 clays <br /> unless otherwise specified in the Inspection R rt. <br /> Note: AJ!EHD staff time associated with fang 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 documeatinv what corrective actions were taken or will be taken for each violation <br /> • Collies of sample resuiOmanifests/training records/other appropriate paperwork,and/or photos <br /> verifying corrections <br /> • Operator's certification <br /> Inspection Date: Inspected By: <br /> Facility Address:_ EPA.J #: <br /> I certify under penalty of law that: <br /> 1. 1 have corrected the violations speeified in the Inspection.Report from the above-mentioned <br /> inspection date. <br /> 2. I have personally examined the following doe mentation submitted as proof of compliance FOR <br /> EACH V IOLAnON and I believe the information to be true,accurate,and complete= <br /> Photos Paperwork V Statement <br /> I I am authorized to submit this certification on behalf of the Respondent <br /> 4. 1 airs aware that there are significant penalties for submitting false information,incWng the <br /> possaofimnend/or imp nment for known violations. (HSC 25191) <br /> Name: Title: <br /> SignatDate: fiC� <br /> EI ID 22-02-x005 Rev 08/10 <br />