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01f05/2006 05:53 5035241 <br />4f <br />RUTH HA - BP 0 <br />i <br />SAN COUNW <br />EWMONMENTAL HEALTH DEPARTNEW <br />600 E. Main St, Stockton, CA 95202-3029 <br />Telephone: (209) 468-3420 fax: (209) 4C$-3433 Web: www slgov.crrrJehd <br />1 1; <br />PAGE 01/01 <br />Any MINOR violations noted, in. the "Notice to Cotnpiy' in the attached .laspection, Report must be <br />corrected within 3D days of receipt of this inspection. This certification form trust be submitted to the <br />Environmental Hcaltb Department (P -HD) address at the top of this form within 35 days of receipt of the <br />Inspection Report. <br />All correctior►s. to other viylatiops noted in the attached Inspection Report or Continuation Form, or <br />disputes to any violations, are to be submitted using this certification, and rewmed to EHD within 3.0 days <br />unless otlierwise specified in the Inspection Report. <br />Note: ,till V stafil' time associated with failing to comply by the above noted dates will be billed at <br />the current hourly rate ($98). <br />For this Certification to be com�?let� ti c operator of the site must Tic. -ode: <br />• ,A statement documenting what corrective actions Were taken or will be taken for each violation <br />® Copies of sample re ius/manifests/ttraining records/other appropriatepaperwork, and/or photos <br />verlfying corrections <br />Inspection Date:^ P �G� Inspected $y: 69ize 4_G Z t <br />Facility ,address: jn, rziu/xi �n x : ' /� 0 a .2 2. Y 1Y <br />, <br />I certify under penalty of law that: <br />l . I have aometed the violations specified .in the Inspection Report from the above-mentioned <br />inspection date. <br />2. I have personally examined the following documentation submitted as proof of compliance FOR <br />EACH VIOLATION and I believe the infor. taxation to be true, accurate, and complete: <br />Photos Papczwoek. Statement <br />3. I am authorized to submit this certification on behalf of the Respondent. <br />4. I arra aware that there are significant penalties for submitting, false information, .including the <br />possibility of a. fine and/or imprisonment for known violations. (HSC 2519 1) 1 <br />/1i ewv�l � <br />Name: Title. <br />Date: 6 <br />ERD 22-02-005 Rev 10-07 <br />