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0, <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />304 East Weber Avenue, P Floor, Stockton, CA 95202.2708 <br />Telephone: (209) 468-3420 Fax. (209) 468-3433 Web: www.sjgov.orgLSh,-d <br />11`11`11!111i� W111mw Moo <br />Any MINOR violations noted in the "Notice to Comply" in the attached inspection report must be <br />Qg_egA within 30 days of receipt of this inspection. This certificationform must be submitted to the <br />Environmental Health Department (]✓HD) address at the top of this form within 35 days of receipt of the <br />inspection report. "I <br />All corroctiona 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 60 da <br />unless otherwise specified in the IR. <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 />• Operator's certification <br />Inspection Date Inspected By: It L I <br />Facility Ad&ess: A/. PEPA M#: 4 L <br />I certify under penalty of 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 FOR <br />I <br />EACH VIOLATION and I believe the information to be true, accurate, and complete: <br />Photos _aperwork 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: U L C5,( - Title: - <br />Signature: Date: <br />ho fe <br />EHD 22-02-005 Rev 12-04 <br />Td WdVZ:S0 900E BT 'Upf 'ON XU -4 WOdj <br />