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SAN JOA,QUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 600 Fast Main Street, Stockton, CA 95202-3029 <br /> Telephone: (209)468-3420 Tax:(209)468-3433 Wch:unvw.s' ov.cr ehd <br /> RETU. <br /> TO COMPLIANCE CERTIFICATION <br /> Any AOR violations not d in the "Notice to Comply" in the attached Inspection Report must be <br /> corrected within 30 days of receipt of this inspection. This certification form must be subm.tted to the <br /> Environmental Health Dep rtment (EHD) address at the top of this form within 35 days of receipt of the <br /> Inspection Report. <br /> All corrections to other viol tions Noted in the attached. Inspection Report (IR) or Cot tti:nuat,.on Form, or <br /> disputes to any violations, are to be submitted using this certification and returned to CtID within 30 dans <br /> unless otherwise specified to the Inspection Report, <br /> Note: All ERD staff time associated with failing to comply by the above noted dates -will be biped at <br /> ,,the current hourly gate ($18). <br /> For this certification to b7 Complete the operator of the site must in.lode: <br /> * A statement documenting what corrective actions were taken or Will be taker For �zch violation <br /> w Copies of sample r6sults/manifests/training records/other appropriate paperwork, and/or photos <br /> verifying corrections <br /> e Operator's certiticaiion <br /> h <br /> I +� <br /> Inspection Date: _ Inspected <br /> Facility Address: <br /> I certify under penaltyf l w that: 9 <br /> ._ specified in the Inspection Reportfrom the al:ove-mentioned <br /> I have corrected the violations <br /> inspection date. <br /> 2. I have personally examined the following documentation submitted as proof o17coripliance FOR <br /> EACII VIOLATION and I believe the information to be true, accurate, and cornplcte: <br /> Photos-PjpeMoTk Statement,. <br /> 3. ,i,am authorized to submit this certification on behalf of the Respondent. <br /> 4. I am aware that the a are significant penalties for submitting false information, the uding the <br /> f a frncand/or imprisonment for known violations. (HSC 25191) <br /> possibility o P <br /> Name: r � Iv` Y` Title. �ul Lr\ <br /> Date: <br /> Sag <br /> nature; <br /> Rev 11/07 <br />