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SAN JOAQUIN COUNTY <br />ENvlRoNmENTAL HEALTH DEPARTMENT <br />600 East Main Shvet,.FI • 95202-3029 <br />Any Ml violations noted in the "Notice to Comply" in the attached inspection Report must be <br />92 within 30 days of receipt of this inspection. This certification• <br />Environmental Health Department (EHD) address at the top Of this form within 30 days of rece pt of th <br />inspection i { <br />All cormgWns to other yLolations noted in the attached inspection Report QR) or Continuation Form, or <br />disputes to any violations, are to be submitted using this certification and returned to EHD within 30 du3- <br />unless otherwise specified in the inspection Report. <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 />include:For this certification, to beCoMplete the operator of the site must <br />documenting what corrective actions were <br />taken or will be taken for each violation <br />Copies of sample results/mariffests/training recordslother appropriate paperwork, and/or photos <br />verifying corrections <br />onspection Date: 7 61 Inspected BY: !A <br />Facility Address: 0 Mae% 48h en— a4. ' #,; <br />V <br />underi certify penalty of <br />inspection1. 1 have corrected the violations specified in the inspection Report from the above-mentioned <br />2. 1 have personally examined the following documentation submitted as proof of compliance FOR <br />EACH VIOLA71ON and I believe the information to be true, accurate, and complete: <br />photos * Paperwork �( Statement <br />3. - 1 am authorized to submit this certification on behalf of the Respondent. <br />4, t am aware that there are significant penalties for submitting false information, including the <br />possibility of a fide and/or imprisonment for known violations. (HSC 25191) <br />Name: -TIH � �N � Titie:�,r.3 Lj--1 k -- <br />Mate. t) 14 _,7 _ 1 awe _; C4 <br />EMD 22-02-M RGV NO <br />