Laserfiche WebLink
E <br />San Joaquin County J U'L 0 7"" 2 0 1 <br />Environmental Health Department <br />1868 East Hazelton Avenue, Stoddon, California 96fli N,, T <br />L H <br />Telephone. (209) 466-3420 Fix: (209) 468-3433 Web., MPffiUjgpv&j5LdW 71, <br />i <br />Arkrj.MU%QQN violations noted in the"N lcl wr"977�1:�• «1..!0 <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 ggagctions to gtb@r yioIMgn1 noted in the aftched inspection Report (IR) or Continuation Form, or disputes to any <br />violations, are to be submitted using this cerfification and returned to EHD withiLn 20 ran unless otherwise specified in the <br />Inspection Report HSC 26185(c)(3) <br />ra-i'705,67WITWifing to comply by Me 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 betaken for each violation <br />Copies of sample resuits/manifestsftraining recordstother appropriate paperwork, and/or photos verifying <br />corrections <br />Operator's certification <br />Inspection Date: September 23, 2013 Inspected By: Elena Manzo <br />Facility Address" 2072 W YOSEMITE AVE <br />MI =10 <br />CERS ID.- 10181669 <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 />_Paperwork <br />& 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 infbirmation, including the possibility of a fine <br />and/or irnaii onrnent for known violations. (HSC 25191) <br />J'JAF UN 1!W <br />Tide: <br />Date: :2-Q <br />It trs `f1��, i�io��t-�1a�( <br />�� n(,y ,�„�/�4,yi�j4'� %tJTiLI Inti x`75-erl (�j�c� GJ� �"1 <br />S*d OOL9tZ960Z do4SNoinb dtO:Z L Lb LO Inr <br />