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It Jan 1, 21 - 10 1 0 .1 8:36a use - 15 3591525 <br />Uil"411"dulu Ut"" ZOIJ40461 130 1-, <br />— SM JOAQW141 COUWIY <br />EWRONmEwAL HF.ALTH Dr--PARTMENT <br />600 East Main Sreet. Stockton, CA 95202-3020 <br />-- <br />INAM NO <br />I tit <br />1iW111Mff*;�1 I&AW i�4[j P -1 W <br />Eftronmwtal Fissilm <br />inspection Report. <br />HEALTH D-r-PATIT, ME14T <br />NI coMg!gons to other vi2tations rated in the attached Inspection Report (IR) or Continuation Form, or <br />disputes to any violations, are tqbe submitted using this certification and Tekime.d to EHD V±ffin 30 dW <br />unless otherwise specified in the Inspection Report. <br />Note: All EHO staff thne associated with -failing to comply by the above noted daWs will �z <br />billed at the -current hourly <br />For this certification to be completethe operator of the site must include: <br />• A statement docurnonfing votatcorrective actions were taken or will be taken for each violation <br />• Copiesof sample resultstmanifests/training recordslother appropriate paperwork, and/or photos <br />verifyinY corrections <br />• Operator's certification <br />Inspection Date: 1)i) JSa Inspected By.' --7- Tro tj <br />Cj <br />F <br />F-PAIM �qR �000 14(05 acliftyAddreorl; CL <br />I cer0ty under penalty oi law th3l: <br />1. 1 have corrected the violations specified in the Inspection Report ftom the abovt,.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 />FEW= <br />1 am authorizeCl to Submit this certification on behalf of the Respondeg <br />W <br />4. 1 am aware that there are significant penalties for submitting false information, including ff <br />0-1,U <br />possibility of a fine and/or imprisonment for known violations, (HSC 2519 <br />c6Lo(' CLS Tme: <br />Date: <br />