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002454 <br />01 0 <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />600 East Main Street, Stockton, CA 95202-3029 <br />Telqp�one. (209) 468-3420 Fax., (200) 468-3433 Web: www.s1gov,orgL2hd <br />jg-� :K4j 4 :4 ffMAQflWZ I <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. <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 30 gays <br />unless otherwise specified in the Inspection Report. <br />Note: All EHO staff time associated with failing to comply by the above noted dates will Ir - <br />billed at the current hourly rate. 11 <br />For this certification to be completethe 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 />inspection Date: F- / 0 - 6 7 - Inspected By: CZ:g4lZAC ff- &gA'tLS <br />Facility Address: -7a7Z _JQKS� L,4V4:- EPAID#: <br />h,0, C)q cl.5Z10 <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. 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 —ZPaperwork V 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 fine and/or imprisonment for known violations. (HSC 25191) <br />Name, <br />Title: <br />f? -C <br />sia,irature- <br />Date* <br />1. S -/j- <br />C) <br />EHD 22-02-005 Rev 08108 <br />