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0 <br />SAN JOAQUIN COUNTY rill" E �U; I!-, IJ WE 0 <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />304 East Weber Avenue, 3`a Floor, Stockton, CA 95202-2708 J U I%% 1 3 2007 <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sj o v.or !,Q ehd <br />EW 1R.T•? lDfi F H E A Uf H <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 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, are to be submitted using this certification and returned to EHD within 60 days <br />unless otherwise specified in the IR. <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 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: S 17- 07 Inspected By: 0 A "0 Q) <br />Facility Address: 44L4 c( Mo,,s dtAe d2,R EPA ID#: <br />r <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 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. I am authorized to submit this certification on behalf of the Respondent. <br />4. I am aware that there are significant penalties for submitting false information, including the <br />possibility of a fine and/or imprisonment for known violations. (HSC 25191) <br />Name: /��c-�- �t dJc w ' Title: GG��-- <br />signature: Date: <br />F,HD 22-02-005 Rev 12-04 <br />