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I'l <br />6A <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT iJ <br />600 East Main Street, Stockton, CA 95202-3029 <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.s*gov.or-q/ehd <br />Any MINOR violations noted in the "Notice to Comply" in the attached Inspection Report must be <br />corrected within 30 da yg 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 30 days of receipt Of the <br />Inspection Report. <br />All corrections to other violations noted in the attached Inspection Report (I R) or Continuation Form, or <br />disputes to any violations, are to be submitted using this certification and returned to EHD 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 <br />billed at the current hourly rate. I <br />For this certification to be completethe operator of the site must include: <br />• 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 />verifying corrections <br />• Operator's certification <br />Inspection Date: i /I2 -10q Inspected By: PA, 4le-)2 te'Z ai <br />Facility Address:�,2; WN=SOptLv <br />/,I- EPA ID#: <br />1 certify under penalty of law that: <br />1. I have corrected the Violations specified 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 Statement <br />3. 1 am authorized to submit this certification on behalf of the Respondent. <br />4. lam aware that there are significant penalties for submitting false information, including the <br />possibi' fafineandlo imprisonment for known violations. (HSC 25191) <br />NamX Title: e:z_ <br />S iQnature � f�Ni �tlt �(.� .�/V Date:,,? <br />EHD 22-02-005 Rev 10/C9 <br />L*d 699L -99t -60Z SJOU8910 mous egt,:O[ 06 60 qe=l <br />