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L�_= <br /> CEUV <br /> Is�� <br /> SAN JdA66,N COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT k;AY 1 4 LdfJ <br /> 600 East Main Street, tdckton, CA 95202-3029 �J ji� <br /> Telephone:(209) 468-3420 Fax (209)468-3433 Web:www.sigov.org/e �� � ( TOEN HFALf H. <br /> RCHMI C,r;-ERVII' S , <br /> RETURN TO COI OLIANCE CERTIFICATION <br /> Any MINOR violations noted in the "Notice to Rorrlply`' it the attached Inspection Report must be <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 tbp of this form within 30 days of receipt of the <br /> Inspection Report. <br /> All corrections to other violations noted in the 6tt9chod;lnspection Report (IR) or Continuation Form, or <br /> disputes to any violations, are to be submitted:U�l�d this cbrtification and returned to EHD within 30 days <br /> unless otherwise specified in the Inspection R�10rt. <br /> Note: All EHD staff time associated witailing to comply by the above noted dates will be <br /> billed at the current hourly rate. <br /> For this certification t0 be Cdi 4ete; the operator of the site must include: <br /> • A statement documenting what corrective aC ions' JveFe 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: / Z-2C( c� Inspected By: <br /> Facility Address: av4.7xGa,1 �f,Q, EPA ID#: t"T G) �'S & <br /> cerfify under penalty,of f law that: <br /> 1. 1 have corrected the violations specified ih the Inspection Report from the above-mentioned <br /> inspection date. <br /> 2. 1 have personally examined the following,documeihtation 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 2519 <br /> � a <br /> Name: 9 l (_t:i P n-` Title: �I e �ilr b r lt�SC� <br /> �i <br /> Sig nature:...---=1 . Date: 'S Ube[ Q c� <br /> EHD 22-02-005 Rev 10/09 <br />