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t1kc )� min',VED SAN JOAQUIN COUNTY MAY ENVIRONMENTAL HEALTH DEPARTMENT . 142013 600 East Main Street, Stockton, CA 95202-3029 Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.s' ov.or /e gi � � ft; um e_ �2c`i >9L L- L) 1 b NCE CERTIFICATION I" Any MIN in the attached Inspection Report must be correctec his certification form must be submitted to the Environr # e top of this form within 30 days of receipt of the Inspectic RnN" L' .J All correi Inspection Report (IR) or Continuation Form, or disputes _ is certification and returned to EHD within 30 days unless o /�/fir 1 ) ruws�'� C 25185(c)(3) Note: A ��Fr Jet " to comply by the above noted dates will be b AML For this Certification t0 be Complete the operator of the site must include: • A statement documenting what corrective actions were taken or will be taken for each violation • Copies of sample results/manifests/training records/other appropriate paperwork, and/or photos verifying corrections • Operator's certification Inspection Date: �� 13 Inspected By:Stacy Rivera Facility Address: 5-7--,3Cj ti(1I,,7.(0' y-64 AW . EPA ID#: certify under penalty of law that: 1. 1 have corrected the violations specified in the Inspection Report from the above-mentioned inspection date. 2. 1 have personally examined the following documentation submitted as proof of compliance FOR EACH VIOLATION and I believe the information to be true, accurate, and complete: X Photos X Paperwork _Statement 3. 1 am authorized to submit this certification on behalf of the Respondent. 4. 1 am aware that there are significant penalties for submitting false information, including the possibility of a fine and/or imprisonment for known violations. (HSC 25191) Name: C. 6,SQI Title: Qw�Je'r Signature: �� ` Date: EHD 22-02-005 Rev 09/11