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0 SAN JOAQIIIN COUNTY 0 <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 600 East Main Street, Stockton, <br /> CA 95202-3029 <br /> Telephone:(209) �k68-3A20 Fax. (209) 468-3433 Web: dN'c 1 d <br /> NCE CERTIFICATI `�N".,-'U�N;,ouatir'y <br /> RETURN TO CQMPLIA <br /> Any MINOR violations noted in the Notice to Comply" <br /> in the attached Inspection Report must be <br /> corrected within 30 daYs of receipt of this inspection. This p ofthisform within 30 days of receipt of the <br /> Environmental Heaion form must be submitted to the <br /> lth Department (EHD) address at t top <br /> Inspection.Report. <br /> All corrections t4 other violations noted in the attached <br /> us nh tIdris certification and returned to spection Report (I R) or Continuation <br /> EHD within 0 da s <br /> disputes to any violations, are to be submitted 9 <br /> unless otherwise specified in the Inspection Report. <br /> Note: All EHD staff time associated with failing to comply by the above noted dates will be <br /> billed at the current hourly tate. <br /> For this certification to be completethe taken <br /> operator of lttaken osite s inclach dolation <br /> a A statement documenting what coarrective actions w <br /> ere Copies of sample results/manifestsltraining recordsfother appropriate Paperwork, and/or photos <br /> verifying corrections Q <br /> . operator's certification C{2 <br /> i <br /> r- p inspected By: �a"" � <br /> ) 5 � 1 <br /> Inspection Date: � <br /> Facility Address: t7c`�� `�' <br /> EPA ID#: C , Ci0034 D <br /> �- <br /> I certify under penalty of law that. <br /> I have corrected the violations specified in the Inspection Report from the above-mentioned <br /> 1. <br /> inspection date. <br /> 2. i have personally examined the following documentation submitted as proof of compliance FO <br /> EACH VIOLATION and I believe the information to be true, accurate, and complete: <br /> photins Paperwork Statement <br /> 3. I am authorized to submit this certification on behalf of the Respondent. <br /> 4. I am aware that there are significant penalties for submitting falso information, including the <br /> l <br /> risonment for Known violations. (HSC 25191) <br /> possibility of a fine and/or imp <br /> Name �, +�r �- Title: W t•-'� <br /> Signature. <br /> bate: 3 I ea <br /> rn.,.,nn nnF Cn,.til lflC} <br />