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JAN -17-2007 oe:53P FROM:GPD+W+G IQUORS INC. 2094634 4 70:4683433 SAN JOAQUIN COUNTY ENVIRONMENTAL HEALT DEPARTMENT 304 East Weber Avenue, 3rd Floor, Stockton, CA 95202-2708 Telephone: (209) 468-3420 Fax: (209) 46N-3433 Web: www.sigov.orgichd r ON It I I I i , fil 15TWI P.1 Any MINOR violations noted in the "Notice to Comply" i1 the attached inspection report must be corrected within 30 days of receipt of this inspection. Thi certification form must be submitted to the Environmental Health Department (EHD) address at the tcp of this form within 35 days of receipt of the inspection report. All corrections to other violations noted in the attached I disputes to any violations, are to be submitted using this unless otherwise specified in the IR. For this certification to be complete the • A statement documenting what corrective actions • Copies of sample results/manifests/training record verifying corrections • Operator's certification Report (IR) or Continuation Form, or an and returned to EHD within 60 days erator of the site must include: taken or will be taken for each violation er appropriate paperwork, and/or photos Inspection Date: jo , il- d 6 Inspected By: —r&a,, Facility Address: 2-517, wfgy=Cjco x.4 I EPA ID#: I certify under penalty of law that: 1. I have corrected the violations specified in the Insl}ection Report from the above-mentioned inspection date. 2. I have personally examined the following docume tation submitted as proof of compliance FOR EACH VIOLATION and I believe the informatio to be true, accurate, and complete: Photos --7---Paper*ork Statement 3. I am authorized to submit this certification on behalf of the Respondent. 4. I am aware that there are significant penalties for submitting false information, including the possibility of a fine and/or imprisonment for know violations. (HSC 25191) Name:__ -a o- i Title: .�.� ee- ,,�` ---- _ I Date: (, //c . ZOO ?- EHD 22-02-005 Rev 12-04