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SAN JOAQUIN COUNTY ENv-MoNmLzNTAL HEALTH DEPAR1UBNT 600 E. Main St., Stockton, CA 95202-3029 Telephone: (209) 468-3420 Fax: (209) 469-3433 Web: w v .&o_v 9r�/zha Any MINOR violations noted in the "Notice to Comply"•in the attaches' Inspection Report must be corrected within 30 days of receipt of this inspection. This certifiication form must be :submitted to the Enviramnental Health Department (I HD) address at the top of this form within 35 days of receipt of the Inspection Report. ' All corrections to other violations noted in the attached Inspection Repgrt or Continuation Form, or disputes to any violations, are to be submitted using this certification acid returned to EHD within 30 clays unless otherwise specified in the inspection Report. Note: All EflD staff time associated with failing to comply by the above noted dates will be billed at the current hourly rate ($y$). For this certification t0 be COi1 Plete the operator of tl}e site must include: A statement documenting what corrective actions were taken o will be taken for each violation �+ Copies of sample results/manifests/training records/other appropriate paperwork, and/or photos verifying corrections 4 Operator's certification Inspection Date: -/0 2-%0-_ r Facility Address: f0 t6 ,$. EPA I certify under penalty of law that: 1. 1 have corrected the violations specified in the Inspection inspection date. from the above-mentioned 2. 1 have personally examined the following documentation sub4tted as proof of compliance FOR EACH VIOLATION and I believe the information to be true, ccurate, and complete: _Photos Paperwork _ Statement 3. 1 ani authorized to submit this certification on behalf of the Rgspondent. 4. 1 ant aware that there are significant penalties for submitting f lse information, including the possibility of a fine and/or imprisonment for kmown violation$. (HSC 2519 1) Name:--- "stn/ t o-tll Title: ; Date: $HD 22-02-005 Rev 10-07