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|J <br />T-xn ^ <br />w~~`�~ ~~�l � San Joaquin County <br />/��]��x�/7/3 '�Oj Emimnmen�|HeeUhD�ed0e� <br />//(�/L/Y/�/� "�~/y ��`^ /`T 1888East Hazelton Avenue, Stockton, California O52O5'S232 <br />Telephone: (208)4G8-3420Fax: (2O0)4G8-3433Web: wWw.2gig�o�Lg(gLoh9 <br />Any K80lQRviolations noted inthe "Notice h>Comply" inUh attached Inspection R Must be <br />receipt ofthis inspection. This certification form must be submitted to the Environmental Health Department (EHD) address <br />at the top of this form within 30 days of receipt of the Inspection Report. HSC 25404.1.2(c)(1) <br />All corrections to other violetpns noted in the attached Inspection Report (I R) or Continuation Form, or disputes to any <br />violations, are to be submitted using this certification and returned to EHID AAbt_jQAW unless otherwise specified in the <br />Inspection Report. HSC 25185(c)(3) <br />billed at the current hourly rate. <br />For this certification to be com[]|efe, the operator ufthe 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 ,eoordslotheroppmphato popenxurk, and/o/ photos verifying <br />corrections <br />EPA ID: tA <br />I certify under penalty of law that. <br />1 1 have corrected the violations specified in the Inspection Report from the above-mentioned inspection date. <br />2, 1 have personally examined the following documentation yubmittedeapnoofofoompUenoeFOREACHVlOLAT|0N <br />and I believe the information to be true, accurate, and complete-. <br />Photosrk statement <br />3, |amauthorized 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 possibility pyefine <br />and/or imprisonment for known violations. (HSC 25191) <br />Name:— <br />Signature: —Date: Q 123 <br />4 <br />