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SAN JOAQUIN COUNIre <br />ENviRoNmENTAL HEALTH DEPARTMENT <br />600 East Main Street, Stwkon, CA 95202-3029 <br />Telephone.- (209) 468-3420 FdLv.- (209) 468-3433 Web: www.AjZ2vorg/ehd <br />119WIIIJ-� := MIRIEWN45101WA-VI <br />Any MINOR violations noted in the "Notice to Comply" in the attached inspection report must be <br />corrected within 30 dap 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 />1115poudon report. <br />All corrections to other 'violations noted 11i tho. attached Inspection Report (IR) or Continuation Form,, or <br />*q■WLW--A-■X ?at AA,-U.W1 <br />unless otherwise specified in tbe IR - <br />For this certification to be complete the operator of aic site must includill <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: 0 — Ff"n :7 Inspected By:_t4t,,6jj fe-- <br />Facility Address: <br />EPA ID#: CAL-po oxg -1 <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 wilipliance 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 ani aware that there are significant penalties fbr submitting false information, including the <br />possibility of a fine and/or imprisonment for known violations. (HSC 2519 1) <br />Date: / , — <br />E14D 22-02-005 Rev 05/07 <br />VO 39Vd 3A83SAIMA Z90ZZE860Z 9Z:90 L00Z/01/0T <br />