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.—IN <br />SAN IOAQUIN COVKry <br />CRONMENTAL HEALTH DUARTMENr <br />600 S, Mak St, S .CA Q52tt22-3029 w . <br />Telephone: (209) 468-3420 Fair (209) 468.3433 Web: emw,$j&gjy.or <br />RETURN TO CONTLIANCE <br />CERTIFICATION <br />Any MPR violations noted in the "Notice to COMPIY' in the attached Inspection Report most be <br />corredtd within 30- day, of receipt of this inspeetioA. xhis eezti£ication form must be subinitted to the, <br />Environmental Health Dep int (ElHD) address at the tap of this £onn within 35 days of receipt of the <br />Impaction Report. <br />All <br />1 Dug IIQ Other i,:!!„(, noted iU the <br />;.tom of InSpeeflon Report or Continuation "oit or <br />dl;", �Y �. �. .. ,1. ! !: _ al: -i / � , _ ��+.:i ;.i fi. - /#■ i � � ' 1�. 1: , t <br />Nate: All ZED staff time associated with failing to comply by the above noted dates will be billed at <br />the eu►rreat hourly rate ($115). <br />• A, statement documenting what eotmtive actions were taken or will be taken. #or each violation <br />• Copies of sample rMults/Muffests/trahiing recordslother appropriate paperwork, and/or photos <br />verifying corrections <br />• Operator's certification <br />sr � <br />Facility Address <br />i <br />L12311.=, <br />11.=, <br />I have ! _ tel. theviolationsspecified inthei _st ! s l R" 1 i figm the 3.' : 1! .1 Y..1, _!. <br />inspectiondata. <br />2. 1 have personalty examined the following doc=ent4on submitted es proof of compa=ce 17OR <br />BACH VIOLATION aaad I believe the information to be time, t,:; and complete: <br />Photos X—Peperwork—Stat=ent <br />r = i.` t to submit thiscertification on behalf!.the <br />i!lni <br />4. I am aware that there are signiti mt penalties for submitting else infb=ation, including the <br />possibility of a fine and/or impriso=ent 'far known. violations. (HSC 2519 1) <br />Nmnc: -M. `) t Title: <br />�AIRA <br />