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SAN JOA,QUIN COUNW <br />F_NVMDNWWAT, HEALTH DEPAR.Tm�NT <br />600 E. Main St, Stockton, CA 95202,3029 <br />Tekephone. (209) 468-3420 Far. (209) 46$-3433 Web. www.sjgov_org/ehd <br />REVJRN TO CONOLIANCE CERTIFICATION <br />RECEIVJAN 14 2013 1 <br />EWIR6NMENTAL <br />EALTH DEPARTMENT <br />Any MINOR violations Wed in the "Notice to Comply" in the attached Inspection Report must be <br />orrrepted within 30 days of receipt ofthis inspection- This certification form must be submitted to iJhe <br />Environmental Health Department (EHD) address at the top of this fonn within 35 days of receipt o the <br />Inspection .Report. <br />All corrections to other violations noted in the attached Inspection Report 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 />Note: All EH.D staff time associated with failing to comply by the above noted dates will be bided at <br />the current hourly rale ($1X). <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/manifestshrain records/other appropriato paperwork, and/or phgtoa <br />verifying corrections <br />* Operator's certification <br />Jnspgction Date: Inspected By: T a <br />Facility Address: 5 %F t Z - EPA 1D#: <br />�-) 7aA-C-y <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. I 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 />I'totos 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 k a wn violations. (HSC 25191) <br />�j <br />Name: 6 Title - <br />Date: I --1 4- — <br />EHD 22-02-005 Rev 08/10 <br />H/Ta 31-'i d GOIDA r^i, 9 3N1] V 9i9L1CCHOZ 6c:9T 6T13Z,,'t,T/Tt3 <br />