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Apr 06 05 10:34a Bagley Enterprise c (2 367-5424 p.2 <br /> SAN JOAQUII+t COUNTY <br /> ENVIRONMENTAL HEAU-M DEPAIt771 jeNT <br /> 304 East weber Avenue,3`d F100r,Stoc1t0x,CA 95202-2748 <br /> -relephOne:(209)468-3420 Fix:(209)468.3433 Web:www,;.j rx&. eh <br /> RETURN TO COMPLIANCE CERTIFICATION <br /> Any MINOR <br /> wi4Mons noted M*' 'the"Notice to Comply"in the attached inspection report must be <br /> corrected within-30 days of receipt of this inspection. his G ration form must be submitted to the <br /> Environmental Health Department(EHD)address'at the to of this form within.35 days of receipt of the <br /> inspection report. <br /> All corrections to other violations noted in the attached]�*Ction Report(IR)or Continuation Form,or <br /> disputes to any violations,-are to be submittedusing this celtificatiola and returned to EHD` iL <br /> unless otherwise specified in the IR. <br /> in_6o days <br /> For this Certification-to be Complete th6 operator of the site must include: <br /> • A statement dqcuwn,twhat corrective actions were taken or will be taken for each violation <br /> * -Copies of sample <br /> ' Vc�fytng COYrPCtIQrJeaSs.u.._tts/mani ets/tano_.n.$..re.c.o...r.,r' <br /> ..s <br /> ...... .;..�0,14W._ alpropriate paperworh. <br /> and/or photos <br /> • Operator's certification <br /> Inspection Date: nsp <br /> ec#ed � <br /> Facility Address: <br /> X certify under p tyof lawn;that: <br /> 1. Ibavecc>rrected'ttt viataons <br /> .,� ,. �,y w slecifd. tttd n' Leport£rom the above-mentioned <br /> 2. I have personally examined the following docwmgnta!tion,submitted as proof of compliance FOR <br /> EACH V10 'I' C)1'� ' d I believe the infozxnatto to be true;accurate,and complete: <br /> • to <br /> . . ,.. ment <br /> 3. Tana authzorized,TQ:;Subtaiit dais oad6 on <br /> b",'Af Ofthegespondent. <br /> 4. 1 ani aware that there are si flcant ' <br /> gcti Penalties for subznitaing false information,including the <br /> possibility pt A f*,and/or imprisonment for lmov&vxolations,(HSC 25191) <br /> Name: `X°2tle_ <br /> Signature: <br /> EM 22-02-005 Rev 12-04 <br />