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0 i=n <br />SoOD 0 <br />SAN JOA UIN COUNTY RECEIVI.I.Or <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />1868 East Hazelton Avenue, Stockton, California 95205-6232 <br />�L�t c► tT rone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sigov_org/ehd <br />_ENVIRONMENTAL HEALTH <br />1Tti'n1r• <br />pE?A §MRN TO COMPLIANCE CERTIFICATION <br />Any MINOR violations noted in the "Notice to Comply" in the attached Inspection Report must be <br />corrected within 30 dans of receipt of this inspection. This certification form must be submitted to the <br />Environmental Health Department (EHD) address at the top of this form within 34 days of receipt of the <br />Inspection Report. HSC 25404.1.2(c)(1) <br />All corrections to other violations noted in the attached Inspection Report (IR) or Continuation Form, or <br />disputes to any violations, are to be submitted using this certification and returned to EHD within 30 days <br />unless otherwise specified in the Inspection Report. HSG 25185(c)(3) <br />Note: All EHD staff time associated with failing to comply by the above noted dates will be <br />billed at the current hourly rate. <br />For this Certification to be complete the operator of the site must include: <br />• A statement documenting what corrective actions were taken or will be taken for each violation <br />• Copies of sample results/manifests/training records/other appropriate paperwork, and/or photos <br />verifying corrections <br />• <br />Operator's certification <br />Inspection Date:_ <br />_� <br />Inspected By: <br />Facility Address: Ir��Z7 }Lf,,'�,,�; �_ EPA ID#: <br />I certify under penalty of law that: <br />'%- V r <br />AUG 2020t4 <br />1. 1 have corrected the violations specified in the Inspection Report from ttnft 1 °NTAL HE+ <br />inspection date. ME <br />ENAr;�`,tix� <br />r ` i� i <br />2. 1 have personally examined the following documentation submitted as proof of compliance FOR <br />EACH VIOLATION and I believe the information to be true, accurate, and complete: <br />Photos Paperwork Statement <br />3. 1 am authorized to submit this certification on behalf of the Respondent. <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 />Name: <br />Signature: F <br />EHD 22-02-005 Rev 04119112 <br />Title: M",, 4,/ <br />Date: 0,0�IL,I <br />