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SAN JOAQUIN COUNT V' 0 <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />600 East Main Street, Stockton, CA 95202-3029 <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sigoy.org/ehd <br />I ]n to it $I <br />VIM "I ri I <br />11 !1 11, ii, I' Bill 1 11 <br />Environmental ftealt1i 1-repartment krAYY—adU—res-s—a1 Ine top of MIS iorm W1111111 Jj uz1jS 0Xi1rXyF,#1L-- <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 EHO within 30 days <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 billed at <br />the current hourly rate ($98). <br />ITAWS "M le <br />runst-iTclude- <br />• A statement documenting what corrective actions were taken or will be taken for -.ach violation <br />• Copies of sample results/manifests/training records/other appropriate paperwork, and/or photos <br />verifying corrections <br />• Operator's certification <br />Inspection Date: '3 i 2��/ e". 31 Inspected By: mq-gj:z -�l <br />Facility Address: 7 -z -go EPA ID#: 000'. <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 Paperwork - &�, Statement <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: 2g8,- <br />) <br />Signature: Date: <br />