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SAN JOAQUIN COUNTY 61 ENVIRONMENTAL HEALTH DEPARTME1 600 East Main Street, Stockton, CA 95202-P29 Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sWpy.org/ehd Any MINOR violations noted in the "Notice to Comply" in the attached Inspection Report must be corrected within 30 days of receipt of this inspection. This certification form must be submitted to the Environmental Health Department (EHD) address at the top of this form within 30 days of receipt of the Inspection Report. All corrections to other violations noted in the attached Inspection Report (IR) or Continuation Form, or disputes to any violations, are to be submitted using this certification and returned to EHD within 30 days unless otherwise specified in the Inspection Report. Note: All EHD staff time associated with failing to comply by the above noted dates will be billed at the current • rate i• $105 (beginning 8/11/09 the hourly rate will •r • this certification to be completethe operator • the site -must include: • A statement documenting what corrective actions were taken or will be taken for each violation • ••- of sample results/manifests/training records/other appropriate paperwork, and/or photos • corrections • Operator's certification Inspection Date: Inspected By: Facility Address: EPA ID#: I certify under penalty of law that: 1. 1 have corrected the violations specified in the Inspection Report from the above-mentioned inspection date. 2. 1 have personally examined the following documentation submitted as proof of compliance FOR EACH VIOLATION and I believe the information to be true, accurate, and complete: Photos Paperwork Statement 3. 1 am authorized to submit this certification on behalf of the Respondent. 4. 1 am aware that there are significant penalties for submitting false information, including the possibility of a fine and/or imprisonment for known violations. (HSC 25191) Name: Title: Signature: Date: EHD 22-02-005 Rev 06/09