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001184 Is <br />' SAN JOAQUIN COUNTY MAY 0 5 200 <br />EN V I ROWd ENTA L HEALTH DEPARTMENT <br />600 East Main Street, Stockton, CA 95202-3029 ENVIRONMENT HEALTH <br />Telephone: (209) 468-3420 Far: (209) 468-3433 Web: www.sigov.orehaPERprP1T/SEFiVICES <br />Any �ITTNIOR violations noted 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 submitted to the <br />Environmental Health Department (I311D) ,('dress at the top of this form within 35 days of receipt of the <br />Inspection Report. <br />All corrections +-_ot?ier N�iolatiorns noted in the attached Inspection Report (IR) or Continuation Form, or <br />disputes to any % solations, are to be submitted using this certification and returned to EHD within 30 days <br />unless otherwise in the Inspection Report. <br />Dote: All EHD staff time associated with railing to comply by the above noted dates will be billed at <br />the c,Prrent hourly rate ($98). <br />FO: this tifical ion i0 be COxi-1plCi;1 the operator of the site must include: <br />® A statcr-cnit documenting what corrective actions were taken or will betaken for each violation <br />Copies results/manifests/raining records/other appropriate paperwork, and/or photos <br />verif" 11" c01 -1'001 i oils <br />f Operator's certification <br />Insp�-ction Date:Z� 0 _ Inspected By: dA1&d40Q1, Ida <br />Faci'ity Ac? ?rr ,:;:_t733_.Q/!'t aGEPA ID#: <br />I certify �r pcmi"! , of law than <br />I I have corrected the violations specified in the Inspection Report from the above-mentioned <br />inspection date. <br />2. I have personallv examined the following documentation submitted as proof of compliance FOR <br />EACH VIOLATION and I believe tlac intermation to be true, accurate, and complete: <br />_Photos ✓ Paperwork Statement <br />3. lam :oriied to subinit this certification on behalf of the Respondent. <br />4. 1 am awe -c Haat there are significant penalties for submitting false information, including the <br />possibility of a fine and/or imprisonment for known violations. (HSC 25191) <br />h,ame: Title:(%Gtii210, <br />Signat tr Date: <br />EHD 22-02-0 * '.ev 11 '­" <br />