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SAN JOAQ UIN COUNTY <br /> ENVIRONMENTAL HEALTH DrPARTMENT <br /> 600 Ernst Main Strwt,Stoddon,CA 95202 <br /> Telephone: (209)468-3420 Fax: (209)468-3433 Web:www.sigYov.or1Z/ehd <br /> RETURN TO COMPLIANCE CERTIFICATION <br /> Any MINOR violations noted in the"Notice to Comply"in the attached inspection report must be corrected <br /> within 30 days of receipt of this inspection. This certification form must be submitted to the Environmental <br /> Health Department(EHD)address at the top of this form within 35 days of receipt of the inspection report. <br /> All corrections ig other violations noted in the attached Inspection Report(IR)or Continuation Form,or <br /> disputes to any violations,are to be submitted using this certification and returned to EHD within 30 days <br /> unless otherwise specified in the IR. <br /> For this certification to be complete the operator of the site must include: <br /> • A statement documenting what corrective actions 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: Inspected By: 4r-77` S <br /> Facility Address: 4 _J -21 EPA ID#: <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 Statement <br /> 3. I 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. (HSC 2519 1) <br /> Name: ICiaz&e Title. q,a tEhe�� <br /> Signature:,r,; Date: Z Z Zj Z4Wg <br /> too[A MW 0Q2 Hag Z£80 ZZS 996 XVJ 6£:60 600Z/ZZ/ZO <br />