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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 600 East Main Street, Stockton, CA 95202-3029 <br /> Rlt``;&410209)468-3420 Fax: (209) 468-3433 Web:www.sogov.org/ehd <br /> AUS 13 z010 ��° . <br /> ENVIRONN,VEN 1 HEALTH <br /> PV9&§T,rSw& )RN TO COMPLIANCE CERTIFICATION <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 (EHD) address at the top of this form within 30 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 /> Note: All EHD staff time associated with failing to comply by the above noted dates will be <br /> billed at the current hourly rate. <br /> For this certification t0 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/manifests/training records/other appropriate paperwork, and/or photos <br /> verifying corrections <br /> • Operator's certification <br /> i a <br /> Inspection Date: j��I r; Inspected By: <br /> Facility Address: a(41"11-3 61'-�-�%:YI,�.S EPA ID#: <br /> 1 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. <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 A. Statement <br /> 3. 1 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 violat,9ps (HSC,25,191)-.._.. <br /> �,,, � • J � � � �..L�L_+,...+'ate <br /> Name: K1, C,d D�A2t Title: ` ....\�' ... � <br /> 7 f s <br /> Signature: `' Date: /f 0 <br /> EHD 22-02-005 Rev 10/09 <br />