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SAN'JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />' 600 East Main Street, Stockton, CA 95202-3029 <br />Telephone` (209) 468=3420 Fax: (209) 468-3433. Web: www.siAov.6M/ehd' <br />RETI.IRN TO COMPLIANCE. E TIFIATI <br />Any MINOR Violationst6oted 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 />disputes to an violations, are to be submitted usin this certification and r=eturned to <br />All corrections to other violations noted in the attached Ins ection Report IR or Continuation Form, or <br />` EHD within 30 days <br />P. Y - g <br />unless `otherwise: specified in the Inspection Report. <br />Note: ,bAll 5HO staffilled at the ctimi eisiaed nt so.cihourt to comp rate.ith failin y the above noted dates will be <br />For this certification t0 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 <br />verifying corrections - <br />• Operator's certification <br />Inspection Date: t t` C> Inspected -ft V6, Iv <br />Facility Address: ` PA ID: <br />f z'o <br />I certify under penalty of law that: <br />1. 1 have correc%d 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 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. I 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 />V <br />inatu re. <br />EHD 22-02-005 Rev 10/09 <br />Title:d Q i <br />Date: J) <br />