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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.sj oqy.orglehd <br />Any MINOR violations noted in the "Notice to Comply" in the attached Inspection Report must be <br />corrected within30 dans of receipt of this inspection. This certification forret must be submitted to the <br />lEnvirorithental Health Department (EHD) address at the top. of this form within 30 days of receipt of the <br />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 <br />disputes to any violations, are to be submitted using this certification and returned to EHD within 30 days <br />unless otherwise specified ire the Inspection Report. HSC 25185(c)(3) <br />Note: All EHD staff time associated with failing to comply by the above noted dates will be <br />billed of the current hourly raise. <br />For: this Cel"tlf[cation t0 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: January 15, 2013 Inspected By: Garrett Backus <br />Facility Address: 2575 Country Club Blvd EPA ID#: <br />I certify. under penalty of law that: <br />1. i 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 />EACH VIOLATION and I believe the information to be true, accurate, and complete: <br />Photos Paperwork K 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 />poss€b' 'ty of a fine and or imprisonment for known violations. (HSC 25191) <br />Name: lee i s Title: SO4-S &a In crSG6 <br />Date: / ///1 <br />EFID 22-02-005 Rev 04119/12 <br />