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10/29/2013 12:38 2093344684 05480 P.001 /003 <br /> a J � <br /> SAN JOAQUIN COUNTY ,gam <br /> ENVIRONMENTAL HEALTH 13EPAP-TMENT ��` �� r.�ii <br /> 98613 Ewt Haaekon Avenue,Stoddoh,Caftmis 9520""232 <br /> Tel one:(209)468-3420 Ic:(209)463-U33 Web:www_slssov.onalehcf E.E1 2013 013 <br /> +{ T COMPLIANCE ■/11� T }w� ■��1►� � •'��..�al <br /> RN <br /> ' I <br /> ATI <br /> Any MINOR tiokHC <br /> oted in the°Notice to Comply'in the ed Inspection Report must be <br /> c:orrecte' within 30 of receipt of this inspection. This tion form must be submitted to the <br /> Environmental Heaepa t(EHD)address at the fop of this form within 30 days of receipt of the <br /> inspection Report. .1.2(c)(1) <br /> • I <br /> All corrections to oth r violations noted in the attached Inspection Report(IR)of Continuation Form,Or ' <br /> disputes to any viola _ns,are to be submitted using this ' n and returned to EHD within 30 dM <br /> s <br /> unless otherwise s ed in the Inspection Report. HSC 25185(c)(3) <br /> Note: All EHD s time associbated with falling to com ply by the above n -.%411 60 <br /> billed at irecurrent hourly,rate. <br /> For this cer#i tion to b complete the operator of the$90 must include: <br /> • A statement menting what corrective actions were taken or will be taken for each violation <br /> + Copies of camp results/manifestsltraining records/other appropriate paperwork,and/or photos <br /> verifying co ns <br /> + Operator's certification <br /> i <br /> Inspection Date': Inspected By: A-K 0-3 <br /> i <br /> Facility Addms: G EPA 1D#: 0 _ <br /> I oer*under pe nalty of law that: <br /> 1. 1 have d the violations specified in tete Inspection Report from•the above-mentioned <br /> inspection date. <br /> i <br /> 2. 1 have pewially examined the following documentation submitted as proof of compliance FOR <br /> EACH VIOUXION and I believe the information to be true,accurate complete: i <br /> Photos_� rkStatement <br /> 3. 1 am autho to submit this certification on behalf of the Respondent. <br /> 4. lam aware Mat there are significant penalties for submitting false infonration,including the <br /> passibility fine and/or impriso nt for known violations_ (HSC 25191) <br /> Name: <br /> I � Title: <br /> Signature U <br /> i <br /> i <br /> 1910 Rwa1119/12 I <br /> i <br />