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APR 0 2Q11 <br />SAN JOAQUIN COUNTY � l <br />ENVIRONMENTALHEALT14 DSPARTMBNT <br />600 East Main Street, Stockton, CA 95202-3029 ° q <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: WWW.sjWv_o :; t <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 35 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 staff time associated with failing to comply by the above noted dates will be billed at <br />the current hourly rate ($122). <br />For this certification t0 be COIllplete the operator of the site trust 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 />• Operator's certification <br />Inspection Date: 4 5 12, b 1 $ Inspected By:r� �� V --CX h <br />Facility AddressQ °i. UO N � _'C4_-ou4 64 EPA IDS#: 0 i,. 00 CD <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 t/ Paperwork Statement <br />3. I 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. (DISC 2519 1) <br />C--�J <br />EHD 22-02-005 Rev 08/ 10 <br />UP <br />Date: q 1-7 (-x© 11 - <br />100 'd Wd LZ:10 i]HZ 110Z—L0—UV <br />