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002454 <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />600 East Main Street, Stockton, CA 95202-3029 <br />Telep!lone: (209) 468-3420 Fax: (209) 468-3433 Web: www.si-qov.o[g/ehd <br />Any MINOR 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 (EHD) address at the top of this form within 30 days of receipt of the <br />Inspection Report. <br />I LZ161 a M*# 07IWM# Mmm� -0 Z <br />WNW NNISIP11M.1w <br />10 14,1106611 0- 0 :0 0 <br />Note: All EHO staff time associated with failing to comply by the above noted dates will bZ <br />billed at the current hourly rate. <br />For this certification to be completethe operator of the site must include: <br />9 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 />9 Operator's certification <br />Inspection Date: t Inspected By: AJRVS <br />Facility Address:_J-- <br />EPA ID#: <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 />EACH VIOLATION and I believe the, information- to be true, accurate, and complete: <br />Photos _Paperwork Z 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 -Po 0�, Aef C Title: <br />.............. ... <br />Signature- <br />Date- <br />EHD 22-02-005 Rev 08106 <br />