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0 A <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />600 East Main Street, Stockton, CA 95202-3029 <br />Telephone: (249) 48-3420 Fax: (209) 469-3433 Web: W&g0vorg)66 <br />To. COMPLIANCE CERTIFICATION <br />Any MINOR violations noted in the *Notice to Comply" in the attached Inspection Report must be - <br />coMe <br />qLed within 30 dayl of receipt of this inspection. This certification form must be submitted tolhe <br />Environmental Health Department (EHD) address at the top of this form wn 30 days of receipt ofthe <br />Inspection Report. <br />;�Ii!! jli� 11111 <br />PM 71 Loll a ' I a I - 0 1 <br />17JIMMM"t 60 <br />unless otherwise specified in the Inspection Report.. <br />Note: All EHD staff time associatedg to comply by the above noted dates will be <br />billed at the current hourly rate. <br />For this certification to be completethe 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 />Operators certification <br />Inspection Date: Inspected By: <br />Facility Address: 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 tr e, accurate, and complete: <br />Photos erwork Statement <br />3. 1 am authorized to submit this certification on behalf of the Respondent. <br />4. 1 am awae th t there are significant penalties for submitting false information, including the <br />possibilittof fin 6 and/or imprisonmenonvio <br />."r violati Iti ns. (HSC 25191) <br />-� <br />Title. Vic <br />Name: e: <br />Signature:,.�'° Date: �% <br />EHD 2Z02-006 Rev 08/08 <br />