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I � I <br /> P I <br /> 3 R <br /> 1 <br /> t <br /> i <br /> i <br /> AN p tP 3 <br /> t <br /> t <br /> EIV 1 PNMENTAt.t°IGf'l.k D r'�t'l(`T GN 3 e <br /> 1868 East H Itr n Av60ue, <br /> at4 kt4n California 95205-6232 <br /> relephorte:(209)4 8 201 Fc:(209)46$-3433 Webiwww.siaovor01ehd <br /> I <br /> RETURN TG,COMPLIANOE CERTIFICATION <br /> Any MINOR violations noted in the "Notice to purply"in the attached Inspection Report must be <br /> cocr cted withlo 30 dM of receipt of this inspection. This,certification form must be subrr)itted to the Environmental Health Health Eepa ent(E address at the top of this form within 3a days of receipt of the <br /> Inspection Report. HSC 25404.1.2(c)(1) <br /> All correctiQUI t_Q othbtviglatlons noted in the attached in etion Report(IR)or Continuation Form,or <br /> disputes t0 any violations, are to be submitted using thisOrbfi tion.and returned to EH0 wnthln <br /> unless othOrwise specified in the Inspection Roport, HSC-25185(c}( ) <br /> I <br /> Plot: SII ata time aasc�ci tec# "tlr faille tv�cor�rply by the above noted dates,will be <br /> billed at the current hourl rate. <br /> i <br /> For this certification t complete the operator of the site roust include: <br /> « A statement documenting what ctivq,;actions ee a Taken or:will a taken for each violation <br /> • Copies of camp%results/manife is trainl r rd foth'er appropriate page ork,ane/or phoWs <br /> verifying corrections <br /> • Operator's certification <br /> a <br /> Inspection Bate: �"�- Inspected By; <br /> Aril'Cacaolt <br /> Facility Address: <br /> EPA I <br /> I certify under penalty of law that: <br /> 1. 1 have corrected the violedons,specified,in the Inspection Report from the above-mentioned <br /> inspection date. <br /> 2. I have personally examined the following documentation sdbrrtitt ° as proof of compliance FOR <br /> EACH VIOLATION and I bell ve the info ation be trues ac rete, and complete: <br /> P otos Pape ;ark Statement <br /> 3. 1 am authorized to submit this certification on behalf of the Respondent. <br /> 4. lam aware that there are significant penalties for submitting false information,including the <br /> po l ' a fine and/or imp °son t for known violations.; (HSC 2 191) <br /> Name:: I Tule: <br /> ig_nature: fat <br /> vt <br /> Y 201 <br /> EHO 22.02.005 Rev 04/19/12 <br /> ENVIRONMENTAL <br /> LTH <br /> 'll <br />