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Any MINOR violations i corrected within 30 days Environmental Health D inspection report. All corrections to other viol disputes to any violations, unless otherwise specified i FO his Certificatl • A statement docun • Copies of sample r verifying correctio 00perator's certific� Inspection Date: Facility Address: t 6 d� S -f - I certify under penalty c C1 I have corrected the inspection date. SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 East Weber Avenue, 3`d Floor, Stockton, CA 95202-2708 one: (209) 468-3420 Fax: (209) 468-3433 Web: www.sigov.or /g ehd pim 30"IJ4 1ZN TO COMPLIANCE CERTIFICATIOrN, ENVIRUNMENT AL LTH DEPARTMENT c�iEt Cl �d in the "Notice to Comply" in the attached inspection repust be receipt of this inspection. This certification form must be submitted to the rtment (EHD) address at the top of this form within 35 days of receipt of the .ions noted in the attached Inspection Report (IR) or Continuation Form, or to be submitted using this certification and returned to EHD within 60 days the IR. t0 be complete the operator of the site must include: ng what corrective actions were taken or will be taken for each violation on records/other appropriate paperwork, and/or photos Inspected By: (Z aA M 0 , • t✓ LD EPA ID#: 4-6 u-� CA -Rs - law that: lations specified in the Inspection Report from the above-mentioned 2. I have personally ex mined e following documentation submitted as proof of compliance FOR EACH VIOLATIO and I belthieve the information to be true, accurate, and complete: Photos aperwork Statement 3. I am authorized to su mit 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 a d/or imprisonment for known violations. (HSC 25191) Name: 13 A- L S I 4—tJ L (= Title: Signature: U_64_4t2!r_ `_sem Date: "t I Ze 6 6 EHD 22-02-005 Rev 12-04 `'�''