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COUNTY <br /> SAN JOAQUINA HEALTH DEPARTMENT <br /> PwIRONMENTAL HE <br /> 304 East Weber Avenue,3`d Floor,Stockton,CA 95202 <br /> Q7o0 or91ehd <br /> Telephone:(209)468-3420 Fax:(209)468-3433 Web:nMy <br /> TURN TO COMPLIANCE CERTIFICATION <br /> RETURN <br /> " in the attached inspection report must be <br /> Any MINOR violations not in the Notice to Comply • in must <br /> daysof receipt of the <br /> s of receipt of this inspection. This certification form be submitted to the <br /> corrected within 30 day p address at the top of this form <br /> Environmental Health Department(EHD) <br /> inspection report. <br /> All disputes <br /> t corrections to other violations noted in the attached Inspection Report(IR) or Continuation Form, or <br /> disputes to any <br /> violations, are to be submitted using this certification and returned to EHD within 60 ays <br /> unless otherwise specified in the M. <br /> OT t�11S Cei'1r1�1Cat10T1 t0 be completethe operator of the site must <br /> e salclen for each violation <br /> F • A statement documenting what corrective actions were taken or will <br /> g records/other appropriate paperwork, and/or photos <br /> • Copies of sample results/manifests/trainin <br /> verifying corrections <br /> • Operator's certification <br /> r <br /> ection Date: Inspected By: <br /> lity Address: <br /> EPA ID=: <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 /> Photos Paperwork Statement <br /> 3. I am authorized to submit this certification on behalf of the Respondent. <br /> 4. I am axvare that there are significant penalties for submitting falseWOMiation,i�j ln�,t <br /> possibility-of a fine and/or imprisonment fortcnawn violations. the <br /> Name: <br /> F1YD 22_02 00`S'Re�12-04 <br /> ��j�. <br />