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SAN JOAQUIN COt1iM <br /> ENVIRONMENTAL HEALTH Da?ARTMEN 7 <br /> 600 E.Mair:St.,Stockxoa,CA 95202-3029 <br /> Telephone:(209)468-3420 Fax;(209)468-343:3 Web:www.sjeov.orQ'ehd <br /> RETURN TO COMMANCE CERTMCAT[ON <br /> Any MINOR violations noted in the"Notice to Comp#y"in tke attached Inspection Report must be <br /> corrected within 30 days of receipt of this inspection. This certification foam roust be subinitted to the <br /> Environmental Health Department(EHD)address at t1w i-op 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 or Continuation Form, or <br /> disputes to any violations, are to be submitted using this certification thin 3 <br /> cation and returned to EHD wi0 days <br /> unless otherwise specified in the Inspection Report <br /> Note: All Elia)staff time associated with failing to comply by the above noted dates will be billed at <br /> the current hourly rate(S98). <br /> For this certification t0 be COMPICte 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 /> Frator's certification <br /> Date: a� /U Inspected By: pK el <br /> dress: OS— frVy Dr EPA ID#: x'under penalty of law that: <br /> 1. I have corrected the violations specified in the Inspection Report frons 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 info/rtnation to be true, accurate,and complete: <br /> Photos ✓ Paperwork Staternent <br /> 3. I 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 2519 1) <br /> Name: Ar J�-IC�rM�t 5 Title: `7­�--_JEM IA)4-L `(�(6 2 <br /> ---------------- <br /> Signature: %�—� Date: 4�5 Q <br /> EHD 22-02-005 Rev f 0_0 <br />