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SAN J O A Q U I N Environmental Health Department <br />Any MINOR violations noted in lhe'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 />at 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 v olations 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 days unless otherwise specified in the <br />Inspection Report. HSC 25185(c)(3) <br />Note: Ail EHD staff time associated with failing to comply by the above noted dates will be <br />billed at the current hourly rate. <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 <br />corrections <br />Operator's certification <br />Inspection Date: ^� iCE . E;iS' <br />I certify under penalty of law that: <br />Inspected By: <br />CERSID: i:i72G�5i <br />1. I have corrected the violations specified in the Inspection Report from the above-mentioned inspection date. <br />2. I have personally examined the following documentation submitted as proof of compliance <br />FOR EACH VIOLATION <br />and I believe the information to be true, accurate, and complete: <br />Photos Paperwork <br />Statement <br />3. I am authorized to submit this certification on behalf of the Respondent. <br />4. 1 am aware that there are significant penalties for submitt <br />ing false information, including the possibility of a fine <br />and/or imprisonment for known violations. (HSC 25191) <br />Name: - �, 1.13,5044LI <br />Title: C�%?C7a�T/cryS d2 <br />Signature: Date: �Z -LI% <br />i <br />1868 E. Hazelton Avenue � Stockton, California 95205 � T 209 46II-3420 � F 209 464-0138 � vnyvvsjcehd.com <br />