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07/3.1/2007 07:59 1209 958 10 PAGE 0'1 SAN JOAQ>UIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 6013 East Main Stmeti Stockton, CA 95202-3429 7-etephme: (209) 468-3420 Fax: (1109) 468-3433 Web. w---VAaov ora/ehd AnyMW OR violations noted In the "Notice to Cotoply" in the attached inspection repo must be 4orrected-within 30 daisof receipt:o;f this inspection. This certification form must be $u itled to the Environmental Health Department (F -HD) address at the top of this form within 35 days receipt of the inspection report. Ail corrections to other violations notod in the attached Inspection Report (IR) or Co disputes to any violations, are to be submitted using this certification and returned to unless otherwise spceified in the lit. For this certification t0- be complete the operator of the site must inc • A statement documenting what corrective actions were taken or will betaken • Copies of sample results/manifests/training records/other appropriate paperwi verifying corrections ® Operator's certification Inspection Date:6�(-Pj p '�_ _ Inspected By: t ___ tion Fora, or within 0 dates. each violation and/or photos u, rx Facility Address:-;? --3 -..l !2� 1�4 - CZ t' ct_A. Un, EP,A. IDS#: LAL- o 0 o p --:3 L4 S / 1 certify uaidet penalty of law that: 1. 1 have corrected the violations specified in the Inspection Report from the abov mentioned inspection date. 2. I have personally examined the following:documentAtion submitter) as proof of 4empliance FOR EACH VIOLATION and I believe the information to be true, accurate, and com plote: Photos Paperwork Statement 3. 1 aryl authorized to submit this certification on behalf of the Respondent. 4. 1 ani aware that there are significant penalties for submitting false information, iIncluding the possibility of a fine and/or imprisonment for known violations. (HSC 25191) 010M Si ,HHD 22-W-005 Rev 05/07