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SAN JOAQUIN COUNTY <br /> ENvIRONmENTAL HEALTH DEPARTmENT <br /> 600 E.Main Sc.,Stodhon,CA 95202-3029 <br /> 2" bogie:(209)468-3420 F (209)468-3433 Web. v._o ehd <br /> RETURN TO COMPLLANCE CERTMCATION <br /> AnyMIN violations noted in the"Notice to Comply"in the attached inspection Report must be <br /> of receipt of this inspection. This certification form must be submitted to the <br /> Envirorun=tal Health Department( address at the top of this form within 35 days of receipt of the <br /> Inspection Report. <br /> All co tions to other vi `ares noted in the attached Inspection Report or Continuation Form,or <br /> disputes to any violations, to be submitted using this certification and returned to FHD within 30 days <br /> unless otherwise specified in the Inspection Report. <br /> Note: All EHD staff time associated with failing to comply by the above noted dates will be billed at <br /> the current hourly rate( 2 <br /> For this certification to be CO Pete the operator of the site must include: <br /> • A statement docurnenting what corrective actions were taken or will be taken for each violation <br /> • Copies of sampleresults/manifests/training records/other appropriate pqxTwork,and/or photos <br /> veriffing corrections <br /> • Operator's certification <br /> Inspection Date: Z—S Inspected By:jh uvfir° <br /> r <br /> Facility Address 374 ' cc EPA ;CAL �'S <br /> I certify under penalty of law t; <br /> 1. I have corrected the violations specified in the Inspection Report from the above-mentioned <br /> inspection te. <br /> . I have personally examined the following documentation submitted as proof of compliance FOR <br /> EACH VIOIATION and I believe the information to be true,accurate,and complete: <br /> Photos japerwork-Statement <br /> 3. I am authorized to submit this certification on behalf of the Respondent. <br /> . I am aware that there significant penalties for submitting false information,including the <br /> possibility of a fineand/or imprisonment for known violations.(HSC 25191) <br /> l e j 'Title. A <br /> Si �4at Date: ` Z <br /> EHD 22-02-005 Rev 08110 <br />