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0 1 0 <br />SAN IOAQUIN COUNTY <br />- utoNmENTALHaaTHDEPAR7mENT <br />1, E. Main St, Stwkton, CA 95202-3029 <br />e <br />T'W, <br />RRA I f , I -j 11 FIrlkrsj 3-9-813111,40 lj�ffeffliyl <br />A statement documenting <br />Copies of saxnplo resultsh, <br />verifying corrections <br />Operator's certification <br />r-aeflity Address: S94 0 <br />I oertif� under penalty of law <br />1. 1 have corrected the <br />inspection date. <br />with failing to comply by the above noted dates will be billed at <br />COMPIete the operator of the site must include: <br />T), <br />specified in the inspection Report from the above-mentioned <br />MAI'My' EM <br />,j <br />S,, -k R <br />,;f Paperwork Z.,StAtement <br />IPM2710,-, =4 <br />4. 1 am aware that there are sim1ficant penalties for submitting false information, including the <br />possibility of a fine and/or iszz risontneat for known violations. (HSC 2519 1) <br />Name:.-,bA%)1t3WZ�, t:f- Title- S��r-g—t 10.^-6e <br />S Date: 6 17_ 1 20 (-2-- <br />EHD 22-02-005 Rev 08110 <br />M d MEM602 << ZMEMON MIS Nodal Aom 6VLL 20-50-F40? <br />