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SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />304 East Weber Avenue, P Floor, Stockton, CA 95202-2708 <br />(209) 468-3433 Web: www.sjgov.orgLe <br />Telephone: (209) 468-3420 Far. <br />I t'] N It U <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 35 days of receipt of the <br />inspection report. <br />iipj��1111 p I•I <br />! 1111!1111:� its) Ilia o 0) <br />UjL5 UCYtHWUL111n NFIT retlmeu tr.-wo7r7m7m,•. <br />unless otherwise specified in the IR. <br />For this certcation to be completethe 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 />WIMUCT"Gromm <br />I certify under penalty of law that: <br />Inspected By: <br />1. 1 have corrected the violations specified in the Inspection Report from the above-mentionj <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 />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 violations. (HSC 25191) <br />ffL =1M <br />14-.1-03W DIZ111r;,=-Paej <br />"m - <br />M <br />