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SAN JOAQUIN COUNTY <br /> ENVIRON%WWAL HEALTH DEPARTMENT <br /> 600 Fad Main Street,SUwkkm,CA 95202 <br /> m Telephone:(209)4468-3420 Fax.(209)468-3433 Web.www.sjo�v.o_rhd <br /> RETURN TO COMPLUNCE CERTIFICATION <br /> .o <br /> z Any X11NOR violations noted in the"Notice to Comply"in the attached inspection report must be corrected <br /> within-30 days of receipt of this inspection. Tins certification form must'be'su - to the Enviroirinental <br /> Health Department(EHD)address at the top of this form within 35 days of receipt of the inspection report. <br /> All corrections to other violations noted in the attached Inspection Report(IR)or Continuation Foran,or <br /> disputes to any violations,are to be submitted using this certification and returned to EHD within 30 days <br /> finless 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 betaken for each violation <br /> • Copies of sample results/manifeswkizining re other appropriate paperwork,and/or photos <br /> verifying corrections <br /> • Operator's certification <br /> Inspection Date: 418108 Inspected Ey: Michelle H <br /> Facility Address: 1234 E.Yosemite Ave. -Manteca EPA : CAR000124420 <br /> I certify under penalty of law*at: <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 VIOI ATION and I believe the information to be true,accurate,and complete: <br /> 0 <br /> Photos Paperwork X Statement <br /> F- <br /> C--3 <br /> 3. I am authorized to submit this certification on behalf of the Respondent_ <br /> 0 <br /> 4. I am aware that there are significant penalties for submitting false information,including the <br /> possibility of a fine and/or imprisonment for known violations.(HSC 2519 1) <br /> Name: Eric Munns Title: HES SMi <br /> o Signature: - -- Date: -- <br /> 0 <br /> �; <br /> N <br /> Q <br />