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SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />1868 East Hazelton Avenue, Stockton, California 95205-6232 <br />Telephone. (209) 468-U20 Fax: (209) 468-3433 Web: oM&hd <br />Any MINOR violations noted in the "Notice to Comply" in the attached inspection Report must be <br />corrected within 30 dans 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. HSC 25404.1.2(c)(1) <br />All corrections to other violations noted in the attached Inspection Report (IR) 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. HSC 25185(c)(3) <br />All EHDistafftime associated with failing to comply by the above noted dates will ..: <br />billed at the current hourly rate. <br />For this certification t4 be complete the 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/manifestsitraining records/other appropriate paperwork, and/or photos <br />verifying corrections <br />• Operator's certification <br />Inspection Date* January 28, 2014 Inspected ByAris Caccipit <br />Facility Address. -1. <br />I certify under penalty of taw that: <br />1. 1 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 1 believe the information to be true, accurate, and complete: <br />PhotosPaperwork Statement <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 information, including the <br />possibility of a fine and/or imprisonment for known violations. (HSC25191) <br />A <br />EHO U -N -M Rev WIW12 FEB 2 12014 <br />jog <br />DEPARTMENT <br />