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002454 <br />. SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />600 East Main Street, Stockton, CA 95202-3M9 <br />:4 ItIll b: k, 0 ji <br />Any MINOR violations noted in the "Notice to Comply" in the attached Inspection Report must be <br />coMeglqd 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 />clisputes to any violations, are to Do SIFIGR littlaultill <br />unless otherwise specified in the Inspection Report. <br />Amis., dates will tR <br />billed at the current hourly rate. I <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 />inspection Date: Inspected By: <br />Facility Address: EPA IN. <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 <br />EACH VIOLATION and I believe the� information to be true, accurate, and complete: I <br />Photos 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 />5M <br />EHD 22.02-005 Rev 08108 <br />