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RECEIVED <br /> sm.lommccuuff �IAY 2 5 2012 <br /> EWVROMWEWAL HMTH DEPAMMIElff <br /> 600 E9W Mom StreK SWdftn,CA 9=2-3= ENVIRONMENTAL HEALTH <br /> Tel (209)468,3=Fav(209)468-3433 WW."WAW0LcgjktW ERM IT/SERVI CES <br /> RETURN TO COMPLIANCE CERTIFICATION <br /> Any MINOR violations noted in the"Notice to Compir in the attached Inspection Report must be <br /> corrected within 30 M of recelpt of tift Inspecdon. This certification form must be subinitted W the <br /> EnvirCrifflental Health Deparfinent(EHID)address at the top of this form within 30 days of recelpt of the <br /> inspection Report HSC 25404.12(c)(1) <br /> AN QqM20=to other violations noted in the attached Inspection Report(111)or Continuation Font,or <br /> disputes to any violations,are to be subatUd using Oils certilik*itim and returned to EH®within 30 gM <br /> unless otherwise specified In the Inspection Report HSC 251 WcX3) <br /> Note: All EHD staff time associaled wfth fWrmg to comply by the above noted dales will be <br /> billed at the cuirrent houdy rate. <br /> For this certification to be complete the opeiaw of the site must in&ww. <br /> • A statement documenffng what corrective actions,were ftken or will be taken fbr each violation <br /> • Copies of sample res"ffiardhokftaining recordslother appropriab paperwork,and/or photos <br /> verifft comections, <br /> • Operaws certification <br /> Inspection Date: Inspected ely: <br /> Fadft Add tvw � EPA W#: <br /> I certify under penalty of law that: <br /> 1. 1 have wffected the,violations specified In the Inspection Raport from the above-mentioned <br /> Inspection date. <br /> 2- 1 have personally examined the k4owing docun*ontstlori submitted as proof of compliance FOR <br /> EACH VIOLATION and I Wave the hibmiallon to be true,acmrate,and complete: <br /> Pholos -Paperwork Statement <br /> 3. 1 am authorized to subn-A this oertification on behalf of the Respondent <br /> 4. 1 am swam that there am significant penalties for submitting false iiftanabon,bv*xlng the <br /> possibility of a fine and/or Irnprisomnent for known violations. (HSC 25191) <br /> Narne. m I-6LteL "e5 Me: <br /> Date: J5 L-2-3b?—_ 0 <br /> Signature: tu 7fr���� <br /> L) <br /> 0OZZ-02-MRWOW11 <br />