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RETURN TO COMPLIANCE CERTIFICATION i x Any MINOR violations noted in the "Notice to Comply" in the attached Inspection Report must be corrected within 30 days of receipt of thais inspection. This certification form must be submitted to the Environmental Health Department (EHD) address at the top of..this form,within 30 days of receipt of the Inspection Report. All corrections to other violations noted in the attached Inspection Report (IR) or Continuation Form, or disputes to any violations, are to be submitted using this certification and returned to EHD within 30 days unless otherwise specified in the Inspection Report Note: All EHD staff time associated ith'failing to comply by the above noted dates will be billed at the current hourly rate.' For this certification to be complete the operator of the site must include: • A statement documenting what corrective actions were taken or wil(be taken for each violation • Copies of sample results/manifests/training records/other appropriatepaperwork, and/or photos verifying corrections • Operator's certifications Inspection Date: Inspected By: Facility Address: 1y Lwenf-en EPA ID:_ i certify under penalty of law that . 1 have corrected the violations specified in the Inspection Report from the above-mentioned inspection date. 2. 1 have personally examined the following documentation submitted as proof of compliance FOR EACH VIOLATION and I believe theJnformation'to be true, accurate, and complete. Photos Paperwork Statement{ 3. lam authorized to submit this certification on behalf of the Respondent. 4. 1 am aware that there are significant penalties for submitting false information, including the possibility of a fine and/or imprisonment for known violations. (HSC 25191) Name: Title:- � Signature: /�,�; . - mate: FN^ 2^ ^2-005 Rev 08108 ENVIRONMTIIEI 600 East Maim t 502 2g Tele'7ona: (209) 468-3 aX: 2 -3d epi• www s�gov.orgg edf VAT RETURN TO COMPLIANCE CERTIFICATION i x Any MINOR violations noted in the "Notice to Comply" in the attached Inspection Report must be corrected within 30 days of receipt of thais inspection. This certification form must be submitted to the Environmental Health Department (EHD) address at the top of..this form,within 30 days of receipt of the Inspection Report. All corrections to other violations noted in the attached Inspection Report (IR) or Continuation Form, or disputes to any violations, are to be submitted using this certification and returned to EHD within 30 days unless otherwise specified in the Inspection Report Note: All EHD staff time associated ith'failing to comply by the above noted dates will be billed at the current hourly rate.' For this certification to be complete the operator of the site must include: • A statement documenting what corrective actions were taken or wil(be taken for each violation • Copies of sample results/manifests/training records/other appropriatepaperwork, and/or photos verifying corrections • Operator's certifications Inspection Date: Inspected By: Facility Address: 1y Lwenf-en EPA ID:_ i certify under penalty of law that . 1 have corrected the violations specified in the Inspection Report from the above-mentioned inspection date. 2. 1 have personally examined the following documentation submitted as proof of compliance FOR EACH VIOLATION and I believe theJnformation'to be true, accurate, and complete. Photos Paperwork Statement{ 3. lam authorized to submit this certification on behalf of the Respondent. 4. 1 am aware that there are significant penalties for submitting false information, including the possibility of a fine and/or imprisonment for known violations. (HSC 25191) Name: Title:- � Signature: /�,�; . - mate: FN^ 2^ ^2-005 Rev 08108