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SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />304 But Weber Avenue, Std Floor, Stockton, CA 95202-2708 <br />Telephone,- (209) 468-3420 FdX: (209) 463-3433 Web. <br />I <br />I <br />CE CERTIFICAT10Y <br />RETURN TO COMPLIAN <br />violations noted in the "Notice to CornPIY" in the attached inspection report mu be <br />form must be submit <br />to 0 <br />receipt of this inspection. This certification th <br />h, Q &Ls of rec ft int <br />0 4 iA <br />.~tpA wit in 3 ss at the top of this form within 35 da is 0 the <br />nvironmenM Health Department (EMD) address <br />inspection report. <br />.All 'o noted in the attached inspection Report (IR) or Con�mqatioAForm, or... <br />� <br />s certification and returned to �Hp wok§gAq 011 <br />are to be submitted using thi <br />:disputes to My violations, <br />"ess otherwise specified in the 1R. <br />ion to becomplete the operator of the site must include;i. <br />- <br />Vor this certificat <br />taken, for each violation <br />9 A statement documenting what Corrective actions were taken or will be <br />® Copies of ;ample results/manifests/training records/other appropriate paperw6rk, andlor'photbs <br />rqpn <br />verifying corrections <br />0 opemtor'i certification <br />Inspected By; <br />,�nspection Date: L I! <br />Facility Address-, &-A ACPP,)f CEPA ID#: <br />I certify under penalty of law that: <br />1. I have corrected the cp <br />violations specified in the inspection Report from the at 0ve-mtionod <br />inspection date. <br />2. 1 have personally examined the following documentation submitted as PMO� of coriliance. P6j <br />EACH VIOLATION and I believe the information to be true, accurate, and �omple* <br />Photos /-Paperwork Statement <br />n behalf of the Respondent. <br />zed to submit this certification 0 <br />3. 1 am authorized <br />4. 1 am aware that there are significant penalties for submitting false information, including thel <br />possibility of a fine <br />and/or imprisonment for known violations. (HSC 25191) <br />Title: <br />Name: <br />Date: <br />Sipa e:' <br />EHD 22-02-005 Rev 12-04 <br />w -d 9t,:60 go-of-inr <br />