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E <br />W7, <br />I <br />San Joaquin County <br />Environmental Health Department <br />1868 East Hazellon Avenue, Stockton, Call 9lik <br />Tellephone: (209) 468-3420 Fax: (209) 468-3433 Web-- www,raioov-ft0AW1 <br />Any MINQR violations noted in the "Notice to Comply" in the attached Inspection Report must be 2g_rLected within 39 dwis of <br />receipt of this inspection. This certification fbrm must be submitted to the Environmental Healitti Department (EHD) address <br />at the top of this form within 30 days of receipt of the Inspection Report. HSC 25464.1.2(c)(1) <br />All ggrregtions to Qftr violaUlapg 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_30-dM unless otherwise specified in the <br />inspection Report HSC 25185(c)(3) <br />Note: All EHD staff time associated with Wing to comply by the above noted dates will be <br />billed at the current hourly rate. <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 rifyi <br />copies of sample results/manifesWraining recordsJother appropriate paperwork, and/or photos ve <br />corrections <br />operator's certification <br />Inspection Date: September 23, 2013 Inspected By: <br />Elena Manz -o <br />Facility Address: 2072 W YOSEMITE AVE CELS ID: 10181669 <br />I certify under penalty of law that <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 fallowing documentation submitted as proof of compliance FOR EACH VIOLATION <br />and I belleve the information to be true, accurate, and complete! <br />Photos Yapemork Statement <br />3. lam 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 possibility of a fine <br />and/or impriWVment for known violations. (HSC 25199) <br />Signature at <br />(� <br />12 gtw-1 ?JAW 76 CC/Ze-� <br />V <br />147; <br />L -d OOL9VZ960Z doqSNoinb dZo: 1.0 L 1, 90 Inr <br />