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Oct 17 11 10:32a Microsoft 916-685-1902 <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />600 East Main Street, Stockton, CA 95202-3029 <br />T efephor:e: (209) 468-3420 Fax. (209) 468-3433 WeG: www.sjgov.ora/ehd <br />r ! r rIla,, <br />p.2 <br />Any MINOR violations noted in the "Notice to Comply" in the attached Inspection Report must be <br />corrected within 30 days of receipt of this inspection. This certification form must be submitted to the <br />Environmental Health Department (FHD) 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, are to be submitted using this certification and returned to EHD within 30 days <br />unless otherwise specified in the Inspection Report. <br />Dote: All EHD staff time associated with failing to comply by the above noted dates will be billed at <br />the current hourly rate ($W). <br />12.5 <br />F®i this certificate®n t® be completethe 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: <br />'7 1 cal I <br />Inspected By: Stacy Rivera <br />Facility Address:/( 6 ./4r-c,�-, EPA ID#: oC. (76 7 " <br />I certify under penalty of law that: <br />1. I 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 25191) <br />Name: <br />EHD 22-02-005 Rev 08/10 <br />Title: <br />Date: <br />