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San Joaquin County <br />Environmental Health Department <br />1868 East Hazelton Avenue, Stockton, California 95205-6232 <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sigov.pLgLe-hd <br />Any MIL40B violations noted in the "Notice to Cornply" in the attached Inspection Report must be �pqrrg itbin �,�yL �_�M of <br />receipt of this inspection. This certification form must be submitted to the Environmental Health Department (EHD) address <br />the too of this form within 30 days of receipt of the 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 disputes to any <br />violations, are to be submitted using this certificabon and returned to EHD)&LjtbLin_j0_days unless otherwise specified in the <br />Inspettion Report. HSC 25185(c)(3) <br />Note: All EHID 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 t,aken or will be taken for each violation <br />Copies of sample results/manifests/training records/other appropriate paperwork, and/or photos verifying corrections <br />Inspection Date: , A2riI 02, 2015 Inspected By: ARI S VELOSO <br />;jIMIK9114MI <br />under penalty of law that: <br />I I have corrected the violations specified in the Inspection Report from the above-mentioned inspection date. <br />I have personally examined the following documentation Submitted as proof c,)f.compliance FOR EACH VIOLATION <br />I believe the information to be true, accurate, and complete'. <br />Photos Paperwork -Statement <br />31 1 am authorized to submit this certification on behalf of the Respondent. <br />I am aware that there are significant pen ies for submitting false information, including the possibility of a fine and <br />imprisonme or known violations. (HS 191 <br />me: <br />RECEIVED <br />APR 07 2015 <br />ENVIRONMENTAL <br />HEAE y DEPARTMENT <br />