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San Joaquin County ­­- L_jl <br />hl- ­ <br />Environmental Health Department ENMRM <br />1868 East Hazelton Avenue, Stockton, California 95205-6232 T <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 Web.- /ehd <br />IN =11 1111, ; 0 0 <br />Any MINOR violations noted in the "Notice to Comply" in the attached Inspection Report must be corrected wlL:hftjQ_dgyj of <br />receipt of this inspection. This certification form must be submitted to the Environmental Health Department (EHO) address <br />at the top of this form within 30 days of receipt of the Inspection Report HSC 25404.1.2(cXl) <br />All corre!Agna t2 other vigkWns 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 EH() in 20 4AY2 unless othenNlse specified in the <br />Inspection Report, HSC 26185(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 corrective actions were taken or will be taken for each violation <br />Copies of sample resultsimanifests/training records/other appropriate paperwork, andfor photos verifying <br />corrections <br />Operator's certification <br />Inspection Date: September 23, 2013 Inspected By: Elena Manzo <br />FacilltyAddresS: 2072 W YOSEMITE AVE CERS ID: <br />I certify under penalty of law that <br />2. 1 have personally examined the fbllo%Wtng documentation submitted as proof of compliance FOR EACH =LATION <br />and I believe the information to be true, accurate, and complete-. <br />-Photos -----Paperwork Statement <br />4. 1 am aware that there are significant penalties for submitting false information, including the possibility of a fine <br />and/or imgMnment for known violations. (HSC 25991) <br />M <br />Date.. 2,2 2 —/ 2 <br />2es gez;�-,tl <br />L*d OOL9tZ960Z do4SNoinb dC0:Z6Ll,L01nr <br />U (U sr <br />San Joaquin County ­­- L_jl <br />hl- ­ <br />Environmental Health Department ENMRM <br />1868 East Hazelton Avenue, Stockton, California 95205-6232 T <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 Web.- /ehd <br />IN =11 1111, ; 0 0 <br />Any MINOR violations noted in the "Notice to Comply" in the attached Inspection Report must be corrected wlL:hftjQ_dgyj of <br />receipt of this inspection. This certification form must be submitted to the Environmental Health Department (EHO) address <br />at the top of this form within 30 days of receipt of the Inspection Report HSC 25404.1.2(cXl) <br />All corre!Agna t2 other vigkWns 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 EH() in 20 4AY2 unless othenNlse specified in the <br />Inspection Report, HSC 26185(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 corrective actions were taken or will be taken for each violation <br />Copies of sample resultsimanifests/training records/other appropriate paperwork, andfor photos verifying <br />corrections <br />Operator's certification <br />Inspection Date: September 23, 2013 Inspected By: Elena Manzo <br />FacilltyAddresS: 2072 W YOSEMITE AVE CERS ID: <br />I certify under penalty of law that <br />2. 1 have personally examined the fbllo%Wtng documentation submitted as proof of compliance FOR EACH =LATION <br />and I believe the information to be true, accurate, and complete-. <br />-Photos -----Paperwork Statement <br />4. 1 am aware that there are significant penalties for submitting false information, including the possibility of a fine <br />and/or imgMnment for known violations. (HSC 25991) <br />M <br />Date.. 2,2 2 —/ 2 <br />2es gez;�-,tl <br />L*d OOL9tZ960Z do4SNoinb dC0:Z6Ll,L01nr <br />