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002454 <br />SAN JOAQUIN COUNTY 0 C T 0 9 2012 <br />ENVIRONMENTAL HEALTH DEPARTMENT gp g,l r1. fa�iO U <br />600 East. MainStreet, Stockton, GA 95202-302.9 NTy <br />N„ 9OUIINCOU <br />Telephone: (209) 468-3420 Fax. (209) 4684433 Web: www.sjgov.ora/ehd HEALIH -NT <br />Any MINOR violations noted in the *Notice to Comply" in the attached Inspection Report must be <br />corrected within 30 days of receipt of this inspection. This certification form must be submitted to the <br />Environmental Health Department (EHD) address at the top of this form within 30 days of receipt of the <br />Inspection Report. <br />All corrections to other violations noted in the attached Inspection Report (IR) or Continuation Form, or <br />disputes to„Any violetio.ns, are to be submitted using this certification and returned to EHD within 30 days <br />unless otherwise specified in the inspection Report. <br />Note: All EHD staff time associated with failing to comply by the above rioted dates will be <br />billed at the current hourly rate. <br />For this certification t0 be compete 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 resuits/manifests/training records/other appropriate paperwork, and/or photos <br />verifying corrections <br />F�FH H] <br />Inspection Date: 64 . Al Zd l2 <br />Facility Address: <br />I certify under penalty of law that: <br />Inspected By: 49is C4 colpo ®” <br />EPAID#: CRL 666o4Si3G <br />1. I have corrected the violations specified in the inspection Report from the above-mentioned <br />inspection date. <br />2. 1 have personally examined the following documentation submitted as proof of compliance FOR <br />EACH VIOLATION and I believe the1nformatiorrto 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 <br />possibility of a fine and/or imprisonment for known violations. (HSC 25191) <br />Name: <br />re: <br />EHD 22-02-005 Rev 08/08 <br />Date- `3 . Z d / 2 <br />