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San Joaquin County <br />Environmental Health Department <br />6 2 0 1 <br />1868 East Hazelton Avenue, Stockton, California 95205-6232 <br />Te one: (209) 468-3420 Fax: (209) 468-3433 Web. www.sigoy-orcrIghd <br />Any MINOR violations noted in the "Notice to Comply' in the attached Inspection Report must be g2rrected ALhjm2Qdays of <br />receipt of this inspection. This certification form must be submitted to the Environmental Health Department (EHD) address <br />at the top of this form within 30 days of receipt of the Inspection Report. HSC 25404.1.2(c)(1) <br />All cocingti2as to yiolgfignp noted in the attached Inspection Report (IR) or Continuation Form, or disputes to any <br />violations, are to be submitted using this certification and returned to EHD within aQ dans unless otherwise specified in the <br />inspection Report HSC 25185(c)(3) <br />ove noted dates %rill be <br />: Waiwasimm <br />MIR 4i t-UMP1111 ej it 4 1 L•11 Itti, A - <br />For this certification to 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/manifests;training records/other appropriate paperwork, and/or photos verifying <br />corrections <br />Operator's certification <br />Inspection Date: September 23, 2013 Inspected By, <br />Facility Add s: 2072 W YOSEMITE AVE <br />I certify under penalty of law that <br />Elena Manzo <br />CERS ID: 10181669 <br />1. 1 have corrected the violations specified in the Inspection Report from the above-mentioned inspection date. <br />2. 1 have personally examined the following documentation submitted as proof of compliance FOR EACH VIOLATION <br />and I be6eve the information to be true, accurate, and complete: <br />phctos _____Paperwo* Statement <br />3. 1 am authorized to submit this certification on behalf of the Respondent <br />ibility of a fine <br />,c I am aware that there are significant penalties for submitting false informa . ton, including the possi <br />and/or Imprisonment for known violations. (HSC 25191) <br />Name: Ttle: <br />00-1 <br />Signatu r Date- <br />) <br />9-d OOL9tZ960Z do4SNoinb dSo: i,o L I, go Inr <br />