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10/29/2013 12:38 2093344684 05480 F.001 /003 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMEttrAL HEALTH DEPARTMENT <br /> .00 <br /> 1868 Est Hazelton Avenue.StaoktM Calilbmie 95205£232 <br /> Tel •(209)468.3420 rr:(209)48&3433 Web.wwar_!W—v c WON , 977 <br /> i <br /> s= j <br /> TO COMPLIANCE CERTIFICATION' <br /> i <br /> Any MINQR violatiloorm noted in the°Notice to Compir in the attached inspection Report must be <br /> 2g ff cae within 30tH <br /> of receipt of#his ins n . This cert' form must be submitted to the <br /> Environ tat Meepa t(EHD)add at the toff of this form in 30 days of receipt of theIn rt. .1.2(c)(1) <br /> All co s tooth vi s noted in the attached Inspection Report(IR)or Continuation Form,or <br /> disputes to any viol at xrs,are to be submitted using this certifitcation and returned to EHD Wain 30 da <br /> unless otherwise speed in the Inspection Report HSC 25185(c)(3) <br /> Note: All END stalf time associated with falling to cofnply by the above noted dates will be <br /> billed at ffm current hourly <br /> For this certi cation to be complete the operator ohne site must include: <br /> • A statement dnting what corrective actions were taken or will be taken for each violation <br /> + Copies of camp resu nifes ining recordslother appropriate paperwork,and/or photos <br /> v+ari{jting co ns <br /> . Operator's certif cation <br /> i <br /> Ins "on te` "' J_" Inspected BY: 1 <br /> A-3 <br /> Facility Address: I,S� EPA IMP. <br /> t <br /> cck- <br /> I oer*under penalty of law that: <br /> 1. 1 have corrected the violations spedfied in the Inspection Report from the above-mentioned <br /> inspectione. <br /> i <br /> 2. 1 have persol ially examined the following documentation submitted as proof of compliance FOR <br /> EACH VIO TION and I believe the inform true,to be tr ,accurate cAm i <br /> Photos_aZaWiwk�Sfaterrnt <br /> 3. lam authorized to submit this certification on behalf of the Respondent <br /> i <br /> 4. lam aware that there are significant penalties for submitting false information,including the <br /> possiblilty'nt fine and/or impriso nt for known violations. (HSC 25191) <br /> Name: 1 G Tete: <br /> Signature- e: to <br /> i <br /> �o R�oarasMz i <br /> I <br />