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0. SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />304 East Weber Avenue, Yd Floor, Stockton, CA 95202-2708 <br />Telephone: (209) 468-3420 Fax. (209) 468-3433 Web: www.sjgov.or&Lehd <br />FiTIT 5 TO rl MOTHM Me 6 1$ is -4 1 1- 0 1 <br />M <br />qt) I Vi6l Kk I ILVAI I I I I I F-111re InT <br />LOP 01 LEIS I0rM W11HIN35 days of receiptot, ie <br />inspection report. <br />1111117•11mr r1lim Igg ji�jgq•iipq• <br />M11111 1`11:1 • <br />�ZIIYdCfllllb,--dLO=�IF-IF07bKllilffCCOIL7LWfIWI�Lb-A;�CitiIV[flI I• <br />=_= <br />ILISPKtob-till "o, ridt 0=04=41 M -11M=611 ON <br />unless otherwise specified in the IR. <br />For this certification 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 />Inspection Date: Inspected By: <br />Facility Address: EPA ID#: <br />I 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 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 violations. (HSC 25191) <br />Name: Title: <br />Signature: Date: <br />EHD 22-02-005 Rev 12-04 <br />