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0 SAN JOAQLgN COUNTY • <br />FNvjRoNmENPAL HEALTH DEPARTMENT <br />600 East Main Street, Stockton, CA 95202-3029 <br />ae: (209) 468-3420 Fax: (209) 468-3433 Web: www sjgov.ors/ehd <br />TO COMPLIANCE CERTIFICATION <br />Any MINOR violations not in the "Notice to Comply" in the attached Inspection Report must be <br />correctcorrectO within 30 days of eceipt of this inspection. This certification form must be submitted to the <br />Environmental Health Depa tment (EBD) address at the top of this form within 35 days of receipt of tht <br />Inspection Report. <br />Alf COT recti ns to other viol tions noted in the attached inspection Report (IR) or Continuation Form, 01 <br />disputes to any vto ations to submitted using this certification and returned to EHD within 30 da <br />unless otherwise specified' ' the Inspection Report. <br />Note: AL EgD staff time ssociated with failing to comply by the above noted dates will be billed <br />the current hourly rate ($ 2). <br />For this certification to be COIT1pletC the operator of the site must include: <br />• A statement docum ming what corrective actions were taken or will be taken for each violatioE <br />• <br />Copies of sampler ults/manifests/training records/other appropriate paperwork, and/or photos <br />verifying correctio <br />• Operator's cert ifica on <br />Inspection Date: 1311q_111 _ inspected By: Ae, fi,e / S CACI <br />Facility Address: lq ." ONT04 eD 10b EPA ID#: CRL D0d__ f 9l T& Z27 <br />I certify under penalty f law that: <br />1. 1 have corrected the violations specified in the Inspection Report from the above-mentioned <br />inspection date. <br />2. 1 have personally examined the following documentation submitted as proof of compliance <br />EACH VIOLATIM and I believe the information to be true, accurate, and complete: <br />Photos Paperwork Statement <br />3. I am authorized to i ubmit this certification on behalf of the Respondent. <br />4. I am aware that the are significant penalties for submitting false information, including the <br />possibility of, of fin and/or imprisonment for known violations. (HSC 25191) <br />Name: N 1 CC l✓) QSIIiFiWl Title: /' ,414jf - EZ <br />Cio nfurP' I, ntr Date: ^r II4111 <br />EHD 22-02-005 Rev <br />