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SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />600 East Main Street, StocktDn, CA 95202-3029 <br />Telephone. (209) 468-3420 Fax. (209) 468-3433 Web: www.sigov.orcilehd <br />I N4 il I " 1 11 N *914 :4 il I a W."I 0 • : <br />?"Rum WOM77-twBuWarm 41j,= <br />Inspection -•r HSC 25404.1.2(c)(1) <br />VIV <br />M c••: <br />billed at the current hourly rate. <br />For this certification to be completethe operator of the site must include: <br />• A statement documenting what corrective actions were taken • will be taken for each violation <br />• Copies of sample resufts/manifests/training recordstother appropdate paperwork, and/or photos <br />• corrections <br />• Operatoes certification <br />Inspection Date: -412-ro 1 (2— _ Inspected By:Stacy Rivera <br />Facility Address: <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.Co-",d1eA- <br />I have personally examined the following documentation submitted as proof of compliance FOP— <br />EACH VIOLATION and I believe the information to be true, accurate, and complete: <br />•• Z< Paperwork Statement <br />U -701f MT I <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 />EMU 22-02-M Rev 09/11 <br />