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San Joaquin County <br />Environmental Health Department <br />1868 East Hazelton Avenue, Stockton, Califomia95205-6232 <br />Any MINOR violations noted in the "Notice to Comply" in the attached Inspection Report must be corrected within 30 days of <br />receipt of this inspection. This certification form must be submitted to the Environmental Health Department(EHID) address, <br />the top of this form within 30 days of receipt of the Inspection Report. HSC 25404.1.2(c)(1) <br />All corrections to other violations noted in the attached Inspection Report (IR) or Continuation Form, or disputes to any <br />violations, are to be submitted using this certification and returned to EHDwithin 30 days unless otherwise specified in the <br />Inspection Report. HSC 25185(c)(3) <br />For this certification to 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 resultstmanifests(training recordslother appropriate paperwork, and/or photos verifying correction: <br />Inspection ate 'E'NA MANZO Inspected BY: EL <br />Facility Address: 17333 SC'.'0MC'0NF.X RE), MAECA EPA 111. <br />2. 1 have personally examined the following documentation submitted as proof of compliance FOR EACH VIOLATI# <br />I believe the information to be true, accurate, and complete: <br />Photos Paperwork Statement <br />.11 11CWTU TIN 0 <br />4. 1 am aware that there are significant penalties for submitting false information, including the possibility of a fine a <br />imprisonment for known violations. (HS025`19i) <br />WM <br />Signature: Date: <br />