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N SAN JOAQUIN COUNTY <br /> EmiRoNmENT LHEALTHDEPARrwENT <br /> a 304 East Weber Avenue,3'0 Roar,SW&bun,CA 95202-2708 <br /> Te gAi9>ye:(209)468-3420 Fou_(204)468.3433 Web:www.sjgou ozere€xt <br /> cC> <br /> 0 <br /> N <br /> T "TURN TO COWLIANCE CERTIFTCATION <br /> o <br /> z • <br /> Any i1IINOR-violations noted in the-Notice to Comply' in the attacb,ad inspection report must be <br /> oouected within 30 days 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 vdthin 35 days of receipt oft1w <br /> inspection report, <br /> All oorrectians to other:solations noted in the attached Inspection Report(IR)or Continuation Form,or <br /> disputes to arty violations,are to be submitted using this certification andretumed to E HD n ithin 60 days <br /> unless otherwise specified in the IR <br /> For this certification to be CO MPICtC the operator of the site mast include: <br /> • A statement documenting what corrective action were taken or will be taken for each violation <br /> • Copies of sample resultstunifiestsr'trainingrocor&other appropriate paperwork,anNor photos <br /> verifying corrections <br /> • Operator's certification <br /> Inspection Date: g-P.d1 Inspected By: dV1i//,,t P/4 <br /> Facility Address:-1 G�q 1(16_*oe EPA IIS#: CA n p0 C 6 V91/91 <br /> � <br /> I certify under penalty of law that: <br /> 1. I have corrected the violations specified in the Inspection Report from the abovomentioned <br /> inspection date_ <br /> 2. I have personally examined the follorsring documentation submitted as proof ofcompliance FOR <br /> EACH VIOLATION and I believe the information to be true,aocurate,and complete: <br /> a <br /> ]Photos �_ PPapperwork k Statement <br /> M <br /> 3. 1 am authorized to submit this certification on behalf of the Respondent <br /> s, 4. I am aware that there are significant penalties for submitting false h formation,including the <br /> K= - possibility of a fine and+or imprisonment for known violations.(FISC 25 19 1) <br /> N <br /> I 0 cel e <br /> T�-ane:t' �pJV �RJ�GISc � Title: <br /> o Signature: sh � � Date: <br /> EHD 22-02-005 Rev 12-04 <br />