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San Joaquin County <br />Environmental Health Department <br />1868 East Hazelton Avenue, Stockton, California 95205-6232 <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.si ov.o /ehd <br />Any MINOR violations noted in the "Notice to Comply" in the attached Inspection Report must be corrected within 30 days of <br />receipt of this inspection. This certification form must be submitted to the Environmental Health Department (EHD) address; <br />the top of this form within 30 days of receipt of the Inspection Report. HSC 25404.1.2(c)(1) <br />All corrections to other 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 within 30 dans unless otherwise specified in the <br />Inspection Report. NSC 25185(c)(3) <br />billedNote: All EHD staff time associated with failing to comply by the above noted dates will be <br />at the current hourly <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 corrections <br />Inspection Date: June 02, 2016 Inspected By: ELENA MANZO <br />Facility Address: W , MANTECA EPA ID: <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 prof of compliance FOR EACH VIOLATION <br />1 believe the information to be true, accurate, and complete: <br />Photos '✓ Paperwork Statement <br />3. 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 information, including the possibility of a fine and <br />imprisonment for known violations. (HSC 25191) 1 <br />Name: lu4er6— 6aZ�-- Title: yr rom-yi iNvt�w.JH�v-iRti , <br />Signature: t /�, - Date: 7— I— IL <br />