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PUBLIC AALTHSERVIOES ,o <br />P�U'N C <br />..� <br />SAN JOAQUIN COUNTY Q .z <br />ENVI ONMENTAL HEALTH DIVISION H: <br />Ernest M. Fu imoto, M.D., M.P.H., Acting Health Officer <br />304 E. Weber Ave., 3rd Floor • P. O. Box 388 •Stockton, CA 95201-0388 °4�; F o Rt <br />209/468-3420 <br />C <br />F RETURN TO COMP <br />In the matter of the Violation(s) cited on 4 <br />As Identified in the inspection Report dated <br />Conducted by �%%i C � flc2 <br />/,r� J-<1 i.7* (agency or agencies) <br />I certify under penalty of law that: <br />1. Respondent has corrected the violations specified in the notice of violation cited <br />above. <br />2. 1 have personally examined any documentationattached to the certification to <br />establish that the violations have been corrected <br />3. Based on my examination of the attached documentation and inquiry of the <br />individuals who prepared or obtained it, I believe that the information is true, <br />accurate, and' complete. <br />4. 1 am authorized to file this certification on behalf of the Respondent. <br />5. 1 am aware that there are significant penalties for submitting false information, <br />including the ossibility of fine and imprisonment for knowing violations. <br />� L <br />Name (Print or Typ) Title <br />Signarre Date Signed <br />Company Name EPA ID. Number <br />A Division of San Joaquin County Health Care Services <br />