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SAN JOAQUIN COUNTY F-WIR6NMENTAL HEALTH DEPAMIENT 600. East Win Street,'Stockton, CA 95202-3029 Telep zon a. '(209) 468-3420 Fax: (M% 48Z433 Web: W" .3MI -_0_MtN Any MINOR violations noted in the "Notice to Comply" in -the attached Inspection Report must be corrected within 30 days of receipt of this inspection- This certification form must be submitted to the Environmental Health Department (EHD) address at the top of this form within 30 days of receipt of the Inspection Report. All corrections to other violations noted in the attached Inspection Report (IR) or Conti ' nuation Form, or disputes to any violations, are to be submitted using this certification and returned to EHD within 30 days unless otherwise specified in the Inspection Report, Note; All 18HD staff time associated with failing to comply by the, above noted dates wfll be billed at the current hourly rate. For this certification to be complete the operator of the site must include- • A statement documenting what corrective actions Were taken or will be taken for each violation Copies of sample resufts/manffeststtraining records/other appropriate paperwork, and/or photos verifying corrections a U Inspection Date:' Inspected, By: Faclift Addrm:V_jTV_a EPA ID#: I certify under penalty of law that: 1.. 1 have corrected the Violations specified in the Inspection Report from the above-mentioned inspection daie. 2, f have personally examined the following dolcumer)Alation submitted as proof of compliance. FOR EACH VIOLATION and I believe theI�inf nA be true accurate, and complete: Photos —Paperwork statement 3. 1 am authorized to submit this certification on behalf of - the Respondent. 4. 1 am aware that there are significant penalties for submitting fafse information, including the possibility of a fine and/or imprison t for known violations. (HSC 25191) Name: oef Siqnature: Date: %�..S/, TTO/ ZOO'd GL90# 9Z:90 90OZ/ZZ/LO