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SAN JOAQUIN COUNTY <br /> '00,1Z ENVIRONMENTAL HEALTti DEPARTMENT <br /> 13 va 1868 r-Amst Hazelton Avenue,stoddon,California 95205-6232 <br /> T81* <br /> Oo <br /> PF2(g)468-3429M <br /> � 342o faw(209)468-3433 Iffliah:" <br /> , 0"' 1 <br /> o <br /> UR� TO COMPLIANCE CERTIFICATION <br /> Arty=NR violations noted 16 the'Notice to Comp'in the attached inspection Report must be <br /> Xted --Inlq—dm of 1pt of this inspection. This cerfificat'on form must'be submitted to the <br /> trivironMenial Health DeqpA nt(EHD)address at the top of this lbffn within 30 days of receipt of the <br /> ­i� -4 a e <br /> Ins ion eport. HSG .1.2(c)(1) <br /> ped . ", 4 <br /> All co oth 1 tions ndtdd in the attached !ns ion Report(IR)or Continuation Form,or <br /> yl <br /> y v <br /> disputes to ny viola ons,6�rmq be submitted using this certification and returned to F-HD MbjM3fijffiLs <br /> .10 1 Er Q 7 <br /> unless tithe me specified in , e!ns ion Report. HSC 25185(c)(3) no dates Will be <br /> Mote: All MD emu firne q9sociated with failing to comply by the above <br /> bill d at the cu .n rate. <br /> For thi certificatinn to be coingletethe operator of the site must include: <br /> • A Mat ment documenti what corrective a ons were taken or Will be taken for each violation <br /> • Copi of sample resualmanifestaftraining records/other appropriate pMerwork,and/or photos <br /> verifying Corrections <br /> • Operdoes certification <br /> IpectioDate: Septem er <br /> 94 2012 Inspected By:Garrett Backus <br /> nsll t <br /> C11 <br /> I <br /> Facility Address,5611 E;Waterloo Road EPA ID#: Q t7020 -1—9 <br /> I cartih under penalty of that: <br /> 1. 1 have corraded the 4iolations sfted in the Inspection Report from the above-mentioned <br /> inspection date. <br /> 2. 1 have personally examined the following documentation stibmitted as,proof of compliance FOR <br /> EAOH VIOLATION a6d I believe the info on to bet accurate,and complete: <br /> i <br /> �—Photos Pape rk Statement <br /> 3. 1 ain authorized to supmft this certification on behalf of the Respondent. <br /> 4. 1 ai I n aware that theri are significant penalties for submitting false info tion, including the <br /> poisibility of a fine ar dior imprisonment for known violations. (HSC 25191) <br /> Name: <br /> Signature: Date: 0 <br /> EKD2"2-W5 30VW1W12 <br />