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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1$$8 East Hazeff <br /> Qn Avenue Stockton, California <br /> 95205-6232 <br /> 32 <br /> Telephone(209)468-3420 Fax:(209)468-3433 Web:www.s v org/ehd <br /> TURN TO COMPLIANCE ETAITi <br /> An MINC3 violations note in the" <br /> Any � d Novae to comply"in the attached Inspection deport must be <br /> corrected within 50 days of receipt of this inspection. This certification form must be submitted. e1� 8 2014 <br /> Environmental Health Department(EHD)address at the tap of this form within 30 days of recei t o t e <br /> Inspection Report. HSC 25404.1-2(d)(1) ENVIRONMENTAL HEALTH <br /> All corrections to other violations noted in the attached Inspection Report(I R)or Gontinuaflon[MWWMENT <br /> disputes to any violations, are to be submitted using this certification and returned to EHI)within 30 days <br /> unless otherwise specified in the Inspection Deport. HSC 25185(c)(3) <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 to be Complete 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 /> verifying corrections <br /> • Operator's certification <br /> Inspection Date: 1- --1 Inspected By;Elena Manzo <br /> Facility Address: 341 111�CQtA Dst,„ _ ERA ID#: <br /> I certify under penalty of law that: <br /> I have corrected the violations specified in the Inspection Report:from the above-mentioned <br /> inspection date. <br /> 02 1 ave personally examined the following documentation submitted as proof of compliance FOR <br /> 0A2. <br /> VIOLATION and 1 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. lam aware that there are significant penalties for submitting false information, including the <br /> possibility of a fine and/or imprisonment for known violations. (HSG 25191) <br /> Name: — Title: �..,.( . (- raM g" - <br /> ignature: Date: Alp <br /> #" <br /> EHD 22-02.005 Rev o4178112 <br />