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06/05/15 03:15PH HP LASERJET FAX 2099551865 P.01 <br />San Joaquin County HE <br />Environmental Health Department <br />1868 East Hazelton Avenue, Stockton, California 95205.6232 <br />0 5 2015 <br />Telephone. (209) 468-3420 Fax., (209) 468-3433 Web: nAAW.IKhd <br />REno <br />JTURN TO ® CERTIFINVIRONMENTAL..CK <br />Any MINQ8 violations noted in the "Notice to Comply" in the attached Inspection Report must be Of <br />receipt of this inspection. This certification form must be submitted to the Environmental Health Department (EHD) address, <br />the top of this form within 30 days of receipt of the Inspection Report. HSC 25404.1.2(c)(1) <br />All cqU r <br />@kpjA noted in the attached Inspection Report (IR) or Continuation Form, or disputes to any <br />violations, are to be submitted using thio certification and returned to EHD jjjh_i_njQ-4AA unless otherwise specified In the <br />Inspection Report. HSC 25185(c)(3) <br />Note: All EHD staff time associated with failing to comply by the above noted dates will be <br />billed at the current hourly rate. <br />For this certification to 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 corrections <br />Copies of sample resufts/manifestsitraining recordslother appropriate paperwork, an4lor photos verifying <br />Inspection Date: Ma,'� 1-.)7 ;:.x)'15 inspected By., S"I",ACY <br />-' N <br />Facility Address: 3250 VV HA1'v11AFR L -1j, ST("?CK'T (), 4 EPA la <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 submitted as proof of compliance FOR EACH VIOLATION <br />I believe the information to be true, accurate, and complete: <br />photos _Paperwork _ LK,_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 possibility of a fine and <br />imprisonment for known violations, (HSC 26191) <br />T <br />die <br />Name, aZ <br />Signature: <br />