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Quick STOP Mart 2098254569 p.2 <br /> 0 6 <br /> SAN.TOA QM Co <br /> ENMOMENTAL HEALTH DEPARTMENT <br /> 600 Put Main Shvd,stDcj"n,CA 93202_3029 <br /> T04hoh=(209)468-3420 FA=(209)468-3433 We&-MMy.s <br /> j y.grgielid <br /> RETURN TO COMPLIANCE CERTIFICATION <br /> Any MO violations noted in the"Notice to Comply"in the attached Inspection Report must be <br /> 01105ted MAk 30 dans Of reCeiptof this inspection. This certification form must be submitted to the <br /> Environmental Health Dcpart'nent(F-HD)address at the top Of this form within 35 days of receipt of the <br /> Inspection Report <br /> All 22=i2ns to other violations noted in the attached inspection Report(IR)or Continuation Form,or <br /> disputes to any violations,are to be submitted using this certification and returned to EHD within 10 days <br /> unless otherwise specified in the Inspection Report. <br /> Note: All EHD staff dwe associated with failing to comply by the above noted dates will be billed at <br /> the current hourly rate($122). <br /> For this certification to be complete the operator of the site must include: <br /> 10 A statelentdocumenting what corrective actions were taken or will be taken for each violation <br /> 0 Copies of sample results/manifests/trainitig records/other appropriate pVerwork,and/ <br /> verifying corrections or photos <br /> • OPeMoes certification <br /> Inspection Date:4�*— Inspected By: <br /> Facility Address: EPA M#: <br /> I certify under penalty of law that: <br /> 1- 1 have corrected the violations specified in the Inspection Report from,the above-mentioned <br /> inspection date. <br /> 2- 1 have personally examined the following doctunentation submitted as proof of compliance FOR <br /> EACH VIOLATION and I believe the information to be true,accurate,and complete: <br /> ------Photos--!��_Paperwork V'--Statement <br /> 3. 1 am authorized to submit this certification on behalf of the Respondent. <br /> 4. 1 am aware that there are significant penalties for submitting false information,including the <br /> possibility known violations.Poss' Y of a fmc-and/Or imprisonment for wn ola. ons.(HSC 25191) <br /> Name: Title: 401E <br /> Signature: fit I Date: <br /> -I —�— <br /> EHD 22-02-005 Rev 08/10 <br />