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SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />1868 East Hazelton Avenue, Stockton, California 95205-6232 <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sjgov.or Lehehd <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. HSC 25404.1.2(c)(1) <br />All corrections to other violations noted in the attached Inspection Report (IR) or Continuatio , <br />disputes to any violations, are to be submitted using this certification and return t s <br />unless otherwise specified in the Inspection Report. HSC 25185(c)(3 <br />Note: All EHD staff time associated with failing to comply b the above nt s will be <br />billed at the current hourly rate. b <br />For this certification to be complete the operator o <br />• A statement documenting what corrective actions were taken or will a take=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: July 23, 2014 <br />Facility Address: 983 Moffat Blvd., Manteca <br />EPAID#:' ►0ii <br />I certify under penalty of law that: <br />1. l 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 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 am aware that there are significant penalties for submitting false information, including the <br />possibility of a tine and/or imprisonment for known violations. (HSC 25191) <br />Name: 61 0- Title:�p 10 1',r✓ C+�(' � <br />Date: 0 <br />EHD 22.02-005 Rev 04/19112 <br />