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0 SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />600 East Main Street, Stockton, CA 95202-3029 <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: %wm.sjgov,org/ehd <br />tnvironmenTa�-M-e-a-fM.Pre.pa(LItiefIL kEnjej MOMS at Me 10[J --1W1 MR5 Wifil YTILHIn %:51; 4215 Wi re'WIF7,Ft Wi i <br />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 rate. <br />'For this certification to -;be completethe operator of t ' he site must inciude: <br />• A statement documenting what corrective actions were taken or will be taken for each violation <br />• Copies of sample results/manifests/training recordslother appropriate paperwork, and/or photos <br />verifying corrections <br />• Operator's certification <br />Inspection Date: <br />Inspected By: dA)S <br />Facility Address: 1 p �,o �. 13ictcmpo 4 . LEbx- EPA I D#: CA to on .3 Y 2 - <br />mom <br />1. 1 have corrected the violations specified in the Inspection Report from the above-mentioned <br />inspection date. <br />W -W MOM-11[olk M J14101211glod - <br />I'- Photos '/�' Paperwork �'_ Statement <br />4. 1 am aware that there are significant penalties for submitting false information, including the <br />possibility oof a fine and/or imprisonment for known violations. (HSC 25191) <br />Name: 1<14c,- <br />",-, 4 (e- 7 Title: _ZVICgLIA 1v (I- <br />S i g n a t u re: mjwVWS_T-_,E ,.j /i <br />EHD 22-02-005 Rev 10/09 <br />Date: L/ - I - / D <br />