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12/04/2009 ERI 15: 04 PAX 209468343.j SJC EHU <br /> �OO1i001 <br /> 002454 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAI, HEALTW bEPARTMENT <br /> 600 Cast Main Street, Stockton, CA 95202.3029 <br /> 7elalr'one:(209) 468.3420 Fax:(209)468-3433 Web:tivuw, <br /> s' ov,nr lehd <br /> RETURN TO COMP IANCEF CERTIFICATION � .. <br /> Any MlNb violations noted in the "Notice to Com <br /> correctwithin 3U days o receipt of this inspection, 7'hts certification form ply" in the attached Inspection Report mast be <br /> t=nvlrction R al Health Uep rtment (F-Ht)) address at the top it this form wit must be submitted to the <br /> tnspectian Repo((, within 30 days of receipt of the , <br /> All Cor_ r„ ectipns tpthe(viol <br /> tione noted in the attached Inspection <br /> disputes to any violations--'a e to be submitted using this cert(fratlon <br /> Report(IR) or Continuation Forrn, or <br /> unless otherwise specified i the inspection Report, <br /> and returned to f=Hp with. in 30 days <br /> Nqte: All EWD staff time associated with faifln to CO M <br /> billed at the curre t hourly rate, mply by the above noted dates will be l <br /> For this certification to be complete the operator <br /> s A statement documentin what corrective actions were takenor will fbetaken for site sB ch� ol <br /> ° Copies of sample result mgnifestMraining records/other appropriate a violation <br /> verifying corrections paperwork, and/or photos <br /> �.®n�erator,s certification ....�-_w..�..�..�,.----- -----_•-_..__,._.� <br /> Inspection Date' y - <br /> _�.. ©n inspected By:• // i <br /> �gYTe TV <br /> Facility Address; 9 0 b <br /> I certify under penalty of la that: <br /> I <br /> 1, 1 have corrected the vie ations specified in the Inspection Repoil from the above-mentioned <br /> inspection date. <br /> 2. 1 have personally exami led the follow' <br /> j <br /> EACH VIOLATION and believe the,information to be true, accon urate,urate, and Completefted as proof Of cO : 1=oR <br /> i <br /> Photos Paperwork <br /> ----Statement j <br /> 3, 1 am authorized to submit this certification on behalf of the Respondent. I <br /> 4 1 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 /> i <br /> Name 6 " I n/� -TY " �.__ Title: n't Y <br /> I <br /> Signature• Date, o- 4-09 <br /> E 11:)2.2-0.00:Rev 08(06 <br />