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SAN JOAQUIN COUNTY <br />EWARONMENTAL HEALTH DEPARTMENT <br />W East Main Street, Stockton, CA 95,202-3029 <br />Teleg'3one: (209) 468-3420 Fax., (209) 488-3433 Web., www.§jgov.M1ehd <br />VAR <br />Any MINOR violations noted in the "Notice to Comply" in the attached Inspection Report must be <br />coM@," within. 3_0 gay_s 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 />11111111,111111111 p�ijjprpir 11111 <br />Folffol - ME 1111"Ill � III III � I . 0 1 11 <br />a M11 <br />unless otherwise speed in the Inspection Report. <br />Note: All EHD staff time associated with failing to comply by the above noted dates will be <br />billed at the current hourly rate. <br />For this certification to be complet ethe operator of the site must include: <br />, A statement documenting what corrective actions Were taken or mfill be taken for each violation <br />® Copies of sample results/manifests/training records/other appropriate paperwork, and/or photos <br />verifying corrections <br />a <br />Operator's certification <br />Inspection Date: 0 1— 1 0 Inspected By: AVk< (__QLjA52ir <br />Facillt� V <br />I y AddyAddress: a 3 EPA ID#: CAL_ <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 __V_Paperwork 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- P1 J'o v -A A e -,f PuM-A Title: < <br />Signature, f Date <br />EHD 22.02-006 Rey 08106 <br />