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0 04/27/2005 10:23 209468 FIFTH FLS PAGE 02 <br /> SAN JOAQUIN COUNIN <br /> t MRONMENTAL HEALTH DEPARTMENT <br /> .304 East Weber Avenue;3'd Flocr,St®ckton,CA 95202-2708 <br /> 7etep&one:(209).468-' 420 Fax:(209)468-3433 Web:www sieov_araJCW <br /> RETURN TO COMPLIANCE CERTIFICATION <br /> Any MIN violations noted in the"Notice to Comply"in the attached inspection report trust 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 35 days of receipt of the <br /> inspection report. <br /> All cogNtjI ns to crtbgr violations noted in the attached Inspection Report(IR)or Continuation Forin,or <br /> disputes to any violations,are to be submitted using this certification and returned to EHD within 60 dabs <br /> unless otherwise specified in the IR. <br /> Fox this certification to be completethe 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,andlor photos <br /> vedfyiug corrections <br /> • Operator's certification <br /> Inspection Date: 2 05 Inspected By: fz° VA pts <br /> Facility Address: 5(9 via 90' EPA ID#: C. L-1 D 71� "a®�- <br /> I certify under penalty of law that: <br /> 1. I 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. I 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 25191) <br /> Name. � � t� �- ° Title'_ 49C / <br /> SignatureiL „ . C /� - Date: <br /> EI-YD 22-02-005 Rev 12-04 <br /> T 'd £1►S6-1£6-602 Opue T j0 PPOl e£j,- : T T •b0 82 2nd <br />