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09/22/2006 14:07 2094683433 EHD PAGE 05 <br /> SA�JT¢ ,,UXN COUNTY • <br /> �ENVItOM4 NTAL Iia <br /> � A1.1'H DEPARTMENT <br /> 304 East Weber Avenue,3'Floor,Stcpkton,CA 95202-2708 <br /> rdephene.(209)468-3420 Fax.(209)468-3433 Web;www.siza-grg/eh <br /> RETURN TO COMPLIANCE CERTIFICATION <br /> :Any M1NQR violations noted in the"Notice to Comply"in the attached inspection repoffxhiust be - <br /> corrected within 30 daye of receipt of this inspection. This certification form must be submitted to the <br /> Envirom-rental Health Department(EHD)address at the toll of this formr iithi'n 35 days of receipt'of the <br /> inspection report. <br /> All corrections to other violations rioted in the attached Inspection Report(IR)or Continuation Form;or <br /> disputes to any violations,ane to be submitted using this certification and returned to EHD within 60 days <br /> unless otherwise specified in the IR. <br /> For this Certification t0 be Complete the 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, and/or photos <br /> verifying corrections <br /> • Operator's certification <br /> Inspection Date: 6 (9 Inspected By: N .9N Ct <br /> Facility Address: 72 7Z l i;r s� LH4l,tr BPA ID#: C14L e66 OY S 9dS <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. I 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 V Statement <br /> 3. I am authorized to submit this certification on behalf of the Respondent. <br /> 4. I am aware that there are significant penalties for submitting false information, includiAS the <br /> possibility of a fine and/or imprisonment for known violations. (HSC 2519 1) <br /> Name: .ve- kA2 v,-ele 7`- Title: 1dJ1t21ec4& )1�4d. f� T2s <br /> Signature: .. ._— <br /> Date: ?-717- 46 <br /> EHD 22-02-005 Rev 12-04 <br />