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C7 <br />SAN JOAQUIN COUNTY <br />L:NVIRnNmr-.NrAL HEALTH DFPAR'rmtN1' <br />600 East Main Street, S(ockton, CA 95202-3029 <br />Telephone: (209) 468-3420 Fax. (209) 468.3433 Web: www.~ ov.ur = ehci <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 f(.)rm 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 />Inspection Report. <br />All corrections to other violations noted in the attached inspection Report (IR) or Continuation Form, or <br />disputes to any violations, arc 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 billed at <br />the current hourly rate ($98). <br />For this certification t0 be complete the operator of'the site must include: <br />• A statement documenting what corrective actions were taken or will be taken for •.ach violation <br />• Copiers of sample results/manifests/training; record~/other appropriate paperwork, and/or photos <br />verifying; corrections <br />• Operator's certification <br />inspection Date: 4l'!�-. �� oy -- - Inspected By: <br />Facility Address: 4(f&( M"'c;'s ac&eA- EPA <br />j,A <br />I certify under penalty of law that: <br />l . I have corrected the; violations specified in the Inspection Report frorn 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 I)e true, accurate, and complete: <br />Photo's <br />__ ✓ Paperwork � _ . Staternertt <br />3. lam authorized to submit this certification on behalf of the Respondent. <br />4. I am aware that there arc significant penalties for submitting false information, including; the <br />possibility of a fine and/or imprisonment for known violations. (HSC 25 P) 1) <br />Name: A)(Gk, A01GL✓ic� <br />Date: <br />EHD 22-02-005 Rev 11/07 <br />Ld T 0LEZL*S0Z dHW e T*: T T so 62 .add <br />