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201' <br />San Joaquin County -1 E- A LIF H <br />Environmerdal Health Department <br />I m8 East Hazelton Avenue, Stockton, Cafifomis 95205�6232 <br />Tetephonw (209) 468-3420 F;RX: (209) 468-3433 Web: <br />71 i <br />Any tjINOR violations noted in the "Notice to Comply" in the attached Inspection Report must be g2aq,_cted w' Ip al) days 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 254b4.1.2(c)(1) <br />All goue=05 to gftW_ violations 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 wilhin 3D days unless otherwise specified in the <br />Inspection Report HSC 25185(c)(3) <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 =T&%ve actions were taken or will be taken for each violation <br />Copies of sample resultsfmanffeststtraining recordslother appropriate paperwork, and/or photos verifying <br />corrections <br />Operator's certification <br />Inspection Date: September 23, 2013 <br />Elena Manzo <br />-r as QX: <br />Facility Address: 2072 W YOSEMITE AVE CERS 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 following documentation submitted as proof of compliance FOR EACH VIOLATION <br />and I believe the information to be true, accurate, and complete: <br />Photos Paperwork Statement <br />3. 1 am authorized to submit this certification an behalf of the Respondent. <br />4. 1 am aware that there are significant penalties for submitting false information, including the possibility of a fine <br />andlor imprisonment for known violations. (HSC; 25191) <br />Title: <br />Signatu Date: <br />tT- <br />®t <br />Z,d OOL9VZ860Z doqS�oinb doo: 40 L 6 90 Inr <br />