Laserfiche WebLink
0 SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL.REAM DFPARTMPNT <br /> 304 East Weber Avenue,3,d Floor, Stocktnn,CA 95202-2708 <br /> Telephone:(209)469-3420 rwc;(209)468-3433 W-h. v^yw.sj&ov.orz/ehd <br /> RETURN TO COMPLIANCE CERTIFICATION <br /> Any MINQR violations noted in the"Notice to Comply"in the attached inspection report must be <br /> uorroctpd t I nn must besubmitted.to the <br /> MdLbin 30 days of rocei'p of this inspection. This certification form <br /> Environmental Health Department(EBT)) address at the top of this form within 35 days of receipt of the <br /> inspection report. <br /> All corrections to other violations noted in the attached Inspection Report(IR) or Continuation Form,or <br /> disputes to any violations, tiro to be submitted using this ccrtification and returned to EI4D within 60 days. <br /> unless otherwise specified in the IR. <br /> For this certification to be complete the operator of the site must include: <br /> • A staternent documenting what corrective artion,%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:—AJAf Me Inspected <br /> Facility Address_&,00 E. /�eoV &X— EPA ID#: zxe. -0ox-1 o"( <br /> I certify under penalty of law that: <br /> 1. 1 have corrected the violations specified in the Inspection Report from the above-mentioned <br /> inspection date. <br /> 2. 1 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 ......A Statement <br /> 3. 1 am authorized to submit this certification on behalf of the Respondent. <br /> 4. 1 am aware that there are significant penalties for submitting false information, including the <br /> possibility of a fine and/or imprisonment for known violations. (11SC 25191) <br /> Name: Title: <br /> Signature: Date: <br /> FHD 22-02-005 Rev 12-04 <br />