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10/13/2014 08:42 2097270859 GEORGE'S 02879 P.001 /002 <br /> 0 'SAN JOAQUIN COUNTY <br /> ENvIRONMENTAL HEALTH DEPARTMENT <br /> 1868 East Hazelton Avenue,St n,California"20- 232R/eh�CEIVED <br /> (209),46&3433Web:www.ragoy-org <br /> Telephone:(2.09)46$-3420 F=. <br /> R. <br /> ETU RN TO COMPLIANCE CERTIFICA11MONMENTAL HEALTH <br /> DEPARTMENT <br /> Any MINOR violations noted in the"Notice to Comply" in 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 top of this form within 30 days of receipt of the <br /> Inspection Report. HSC 25404.1.2(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 to 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 Dater)_ ~-i Inspected By:Aris Cacapit <br /> D#: 0065b �X <br /> Facility Address: { EPA <br /> 6 � <br /> I certify under penalty of law that: <br /> 1, 1 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. lam 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 /> . pen or <br /> Possibility f fine and/or impnsy tf known violations. (HSC 25991) <br /> 1 <br /> f\ <br /> Name, Title: <br /> L Signature: Date: 71) <br /> EHD 22-02-W5 Rev 04112M2 ,✓ <br />