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0 San Joaquin County <br />Environmental Health Department LUZ" <br />1868 East, Hazelton Avenue, Stockton, California' 95205-6232 <br />Te/ephone: (209) 468-3420 Fax: (209) 468-3433 Web: www .sigov <br />,,oCgLehd OCT 2 6 20'11 <br />1111111111111 iq��11111 11111q 1111111I�1111�111111 111�11i 11 <br />y. <br />Any MjhLQ3 violations noted in the "Notice to Comply in the attached Inspection Report must beggagg-hed within 30 dpA of <br />receipt of this inspection, This certification form Must be submitted to the Environmental Health Department (EHD) address i <br />the top of this form vviihin 30 days of receipt of the Inspection Report, I-ISC 25404.1.2(c)(1) <br />All 2Qnrr_e_Ck(�Ui_.. -other violations 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 EHD within 30 days unless otherwise specified in the <br />Inspection Report. HSC 25185(c)(3) <br />Rote. All EHD staff time associated with failinq to comply by the above noted dates will be <br />billed at the current hourly rato, <br />For this certification to be complete, the operator of the site must include: <br />A statement documenting what corrective aeflons were taken or will be taken for P-acli Violation <br />Copies of sample results/manifests/training re-cords/other appropriate paperwork, and/or photos verifying corrections <br />Inspection Date: June 10, 2015 _.- — Inspected By,.—FATINAH ZAREEF <br />Facility Address: 3304WFIAMMER_LN, ST0CKT0N EPA 10., <br />I certify under penalty of law that, <br />1, 1 have corrected the violations specified in the Inspection Report from the above-mentioned inspection date. <br />2 1 have persorolly examined the, follawing docurnerlation submitted as proof of compliance FOR EACH VIOLATION <br />I believe the information to be trtAo, accurate, and completc-. <br />-Photos, Paperwork ­Staternent <br />3, 1 am authorized to Submit this cerbfication on behalf of tht? Respondent. <br />4, 1 am aware that there are, significant penalties for submitting false, information, including the possibility of a fine and <br />imprisonment for known violations. (HSC 25191) <br />Signature: <br />rW <br />