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002454 <br />L <br />SAN JOAQUIN COUNTY <br />0 12 <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />600 East MainStreet, Stockton, CA 95202-30$9 <br />Telep:-,one: (209) 468-3420 Fax: (209) 458-3433 Web: www.siaov.ora/ehd <br />L <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 30 days of receipt of the <br />Inspection Report. <br />Ali corrections to other violations noted in the attached Inspection Report (IR) or Continuation Form, or <br />disputes to tiny 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 be <br />billed at the current hourly rate. <br />For this Certification t0 be COI7lpiete the 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 />verifvina corrections <br />Inspection Date: "t XT, Z4 / Z-. Inspected By: S�'qC &'v'`'e.�Q <br />Facility Address: 5®6' A) • /=' of;,J EPA iD : CAL 00 O OM 5"' 7 22 <br />I certify under penalty, of law that: <br />1. I 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 theInformation•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 suhmitting false information, including the <br />possibility of a fine and/or imprisonment for known violations. (HSC 25191) <br />il% �RVA5 O I Title: iR�:'c7�sa- 444'e s <br />re: <br />EHD 22-02-005 Rev 08108 <br />Ry <br />