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-'�0 9— .WW <br />Y , <br />SAN JO,A,QUIN COUNTY <br />ENVIRONN BNTAL MiALTH DEPARTMENT <br />600 E. Main St, Stockton, CA 95202-3029 <br />Telephone: (209) 468-3420 Fax: (109) 46$-3.433 Web: www.gjggv.oraJehd <br />r 09&519061 ' r <br />Any M NOR violations rooted in the "Notice to Comply" in the attached Inspection Report must be <br />corrected within 30 days of receipt oftlus inspection. This certification form must be submitted to the <br />Environmental health nepm1ment (FM) address at the top of this fozau within. 35 days of receipt of the <br />Inspection Report. <br />All, corrections to other violations noted in the attached Inspection Report or Continuation Form, or <br />disputes to any violations, are to be submitted using this certification and nett=ed to EHD witbin 30 dabs <br />unless otherwise specified in the Inspection Report. <br />Note: AU lM staff time associated with failing to comply by the above noted dates, will be billed at <br />the current hourly rate ($12667. <br />For this cerfificat1on 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 sauzple results/manifests/training records/other appropriate Paperwork, and/or photos <br />verifying corrections <br />• Operator's certification <br />Inspection Date: a-/ems/:y Inspected By: i14vy nVO <br />Facility Address: 1 b soca SoLnu HArztAtj Q b EPA: 1D#: CAL --00o Z G o 63 L <br />L.ATltW CA 9 S 9 3 o <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. I have personally exandned the following doctmaentation submitted as proof of compliance FOR <br />EACH VIOLATION and I believe the information to be true, accurate, and complete: <br />Photos _Paperwork statement . <br />3. I am authorized to submit this certification ora behalf of the Respondent <br />4. 1 am aware that there are significant penalties for submitting false information, including the <br />possibility of a fine and/or ivaoprisoouaeat for lnaow,u, violations. (FISC 25191) <br />Name' CA IV Title.• . rm& a gts <br />Date: 3 /1s/ z <br />EHD 22-02-005 Rev 08/10 <br />-N <br />