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W. <br />SANJOAQU04 COU)4TV <br />ENWRONUENTAL HEALTH DEPARTMINTO HE Qij vjiL, <br />1869 E. Hazelton Ave,, Stockton, CA 95205 <br />,relephoire., (209) 468-3420 Fax: (209) 468-3433 Web., F63 0 3 2015 <br />MVI EM =-M a L <br />Any MINC1Xt violations 'noted in the "Notice to Comply" in the attached Inspection Report must be <br />mr—rected within 0 dw of receipt of this inspection. This certification form must be submitted to the <br />Environmental Health. Department (EHD) address at the top of this form within 35 days of receipt of the <br />Inspection Report. <br />All c <br />,qmqctions, to other violations 1note d in the attacbed Inspection Report or Continuation Form, or <br />disputes to any violations, are to be submitted using this certification and returned to E14D yjthin 30 <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 ($125). <br />For this certification to be complete theoperator of the site must include: <br />10 A statement documenting what corrective actions were taken or will be taken for each violation <br />• Copies of sample results/Manifests/training records/other appropriate paperwork, and/or photos <br />vedf�xng corrections <br />• Operator's certification <br />rnspection Date -r - - - Inspected By: Ac�s ije�,osjz <br />Facility Address: 9 S Oq w. L= EpA ID#: <br />I certify under penalty of law that. <br />1. I have corrected the violations specif' <br />..ted in the Inspection Report from. the above-mentioned <br />inspection date. <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 4140M <br />3. 1 am authorized to submit this certification on behalf of the Respondent <br />4. 1 am aware that there are significant penalties for submitting false infonnation, including the <br />possibility of a fine,and/or imprisonment for known violations. (HSC 25191) <br />Name:— Nj�-7� <br />EHD 22-02-005 Rev 07-24-13 <br />Date: 0 Is— <br />