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06/05/15 03:09PM HP LASERJET FAX 2099551865 P.01 <br />I <br />San Joaquin County <br />REG I <br />I V D., <br />...... Environmental Health Department <br />1868 East Hazelton Avenue, Stockton, California 9620232 F� <br />kill <br />44� 0 5 <br />" T6160one. (209) 468.3420 Fox., (2G9) 468.34$3 Web: MMk."5jg9ygrqLe—hd 201 <br />Any A&jN_QR violations noted in the "Notice to Compl)( In the attached Inspection Report must begpZ_qgW within 30.dffia of <br />receipt of this inspection. This certification form must be submitted to the Environmental Health Department (EHD) address; <br />the top of this form within 30 days of receipt of the inspection Report, HSC 25404.1.2(c)(1) <br />All rRMqgUqn <br />to ot'g <br />h2Lyj JAUM noted in the attached Inspection Report (IR) or Continuation Form, or disputes to any <br />violations, are to be submitted using this certification and returned to EHt) WjjhjUA_dWA unless otherwise specified in the <br />Inspection Report. HSC 26185(c)(3) <br />Note: All EHD staff time associated with failing to comply by the above noted dates will be <br />billed at the current hourly rate. <br />For this certification to be complete, the operator of the site must include: <br />A statement documenting what corrective actions were taken or will be taken for each violation <br />Copies of sample results/manifests/training records/other appropriate paperwork, and/or photos verifying corrections <br />inspection Date: May ()'?, 201 r� Inspected By: S*'I"AC"('�"�iVt�.,.i"��A <br />Facility Address: ,,250 VV L.N. 11,"*'T0(.',K1"t.'X,J EPA Ia. <br />I certify under penalty of law that: <br />I have personally examined the following documentation submitted as proof of compliance FOR EACH V1*1LATIOW <br />I believe the information to be true, accurate, and complete: I <br />Photos _Paperwork <br />— 4'—statement <br />$, 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 <br />imprisonment for known violations. (HSC 25191) <br />Tit <br />Name: <br />