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NICK ARBABIAN 9claA729584 p.1 <br /> IF <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 600 East Main Street, Stockton, CA 95202-3029 <br /> Telep'-,ona:(209)468-3420 Fax:(209)468-3433 Web:www.sigov.orWehd <br /> RETURNLI C CERTIFICATION <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 /> 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 in the Inspection Report. <br /> Note: All EHD star time associated with failing to comply by.the above noted dates will be <br /> billed at the current hourly rate. <br /> For this Certification t0 be C®PT plot@ 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 recordslother appropriate paperwork, and/or photos <br /> verifying corrections <br /> « <br /> Operator's certification <br /> Inspection Date: { /-L, l0 g 1 s c 41U 1 A F <br /> 2A 1`✓A)bV <br /> Facility Address: ICS-N) RD LATHW EPA I <br /> 933 c� <br /> 1 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--.Zpaperwork Statement <br /> 3. l 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: .y r�: A 2 Title: 1`tA/) r JA 6-t,_4 <br /> Signature: G-- Date: l"Z-/19/®"S <br /> EHD 22-02-005 Rev 08/08 <br />