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SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />304 East Weber Avenue 39' Floor, Stockton, CA 95202-2709 <br />Tdephone.* (209) 468-3420 Fax: (209) 468-3433 Web. www.sjaov.orgY/ehd <br />177*0711 01FIRT4 31 fl 0 171 1111 111 <br />A I I 111111111911e� <br />q (A I <br />0 Ar - '39 <br />gF. N <br />A <br />TFrTw00_PzW =lf <br />unless otherwise specified in the IR. <br />For this certification to beCOMPIete the operator of the site must include: <br />e A statement documenting what corrective actions were taken or will betaken 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: Inspected By:— (��&,e7 —1 <br />Fac ility Address: 390 tot 9-u " IM-kow9- C." ' EPA ID#: <br />I certify under penalty of law that: <br />1. I 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 Paperwork to went <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: Title: lJ <br />U, <br />Signature: Date: C/A/a 91 <br />­_ _M ^_ 40% ^A <br />