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Jan 19 12 05:52a U68151 3691525 p. 6 <br /> f; C&tt'c i0r. t (`SIS GF"C a A0 .<. `0 C GZ (t- <br /> SAN <br /> tSAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 800 East Main Street, Stockton,CA 95202-3029 <br /> Iphone:(209)468-3420 Fax:(209)4663433 Web:www.siaov.org/ehd <br /> TURN TO COMPLIANCE CERTIFICATION <br /> AnyIM NOR violatio noted in the`Notice to Comply"in the attached Inspection Report must be <br /> correctQd VAthin 30 1 Is of receipt of this inspection. This certification form must be submitted to the <br /> Environmental Healt epartment (EHD)address at the top of this form within 30 days of receipt of the <br /> Inspection Report. C 25404.1.2(c)(1) <br /> All corrections to t L violations noted in the attached Inspection Report(IR)or Continuation Form, or <br /> disputes to any viola i ins, are to be submitted using this certification and returned to EHD within 30 days <br /> unless otherwise spi fled in the Inspection Report. HSC 25185(c)(3) <br /> Note: All EHD stz time associated with failing to comply by the above noted dates will be <br /> billed at th urrent hourly rate. <br /> For this cert "cation to be complete the operator of the site must include: <br /> . A statement do i imenting what corrective actions were taken or will be taken for each violation <br /> • Copies of samE v i results/manifests/training records/other appropriate paperwork, and/or photos <br /> z0fying corfec i,ins <br /> • Operator's cert ication <br /> Inspection Date: Inspected By:Stacy Rivera <br /> 3sN C <br /> acility Address: Loc( EPA ID#: <br /> I certify under ialty of law that: <br /> 1. I have corn d the violations specified in the inspection Report from the above-mentioned <br /> inspection e. <br /> 2. 1 have pers IN examined the following documentation submitted as proof of compliance FOR <br /> EACH VIO ri6N and I believe the Information to be true, accurate,and complete: <br /> Photos Paperwork_Statement <br /> 3. t am authoIree <br /> to submit this certification on behalf of the Respondent. <br /> 4. 1 am awat there are significant penalties for submitting false information, including the <br /> possibilityfine and/or imprisonment for known violations. (HSC 25191) <br /> Name: d �Q, c�� Title: f� .i <br /> Date: /to <br /> Aj <br /> �irynature: d� a /a <br /> EHO 22-02UOS Rev 09111 <br />