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SAN JOAQUIN COUNTY 0 <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />600 East Main Street, Stockton, CA 95202-3029 <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.siclov.org/ehd <br />;1 4N4 :49 , 0, <br />illeja to Sol- y e�x 0 ff* *TJOIGOT11 - 01011 <br />- •loll <br />Inspection Report. <br />All corrections to other violations noted in the attached Inspection Report (IR) or Continuation Form, or <br />disputes to any violations, are to be submitted using this certification and returned to EHD within 30 days <br />unless otherwise specified in the Inspection Report. <br />Note: All EHD staff time associated with failing to comply by the above noted dates will b <br />billed at the current hourly rate. I <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 violatio <br />* Copies of sample results/manifests/training records/other appropriate paperwork, and/or phot <br />verifying corrections <br />* Operator's certification <br />INTITITTIMITI-OrM <br />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 />M =Fffsl 2 WA [01 WIN 1 [01 ilk 1; Fe I I *N1 I 17TIVA I I r_1 I I I Fe Z ZIORKSMIRINIZI <br />ill M1150110KORONS111 - F <br />Photos Paperwork Statemen) <br />1! 11 1 F i; I � I I I I I � I I i I iil��!Ijl I 11111!11l� <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 />SEEM <br />EHD 22-02-005 Rev 10/09 <br />am <br />