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0 SAN <br />JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARDWEW E <br />600 East Main Stmet, Stockton, CA 95202-3029 <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.gav ore%hd <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 />Ali 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 cernfication 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 win be billed at <br />the current hourly rate ($122). <br />For this certification. tO be Complete the operator of the site must include: <br />• A statement documentngg what corrective actions were taken or will be taken for each violation <br />• Copies of sample results/manifests/ g records/other appropriate paperwork, and/or photos <br />verifying corrections <br />• is certification. <br />r <br />Inspection D. . ARR9 <br />Facility Address: (A CA EPA ID#: Ckft 9SIoNt <br />r <br />ty of law <br />1 1 ' penalty 1law <br />t I �1 I ::' I i 1`• iif 11 ;�. 1 !.•. I 1 1: !! 1I 1 1;. <br />2. I 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 Statement <br />3. I am authorized to submit this certification on behalf of the Respondent. <br />4. I 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 25 19 1) <br />Name: +M0 G"�— Title:'i �3 s t.Y i 1 t, P t'ln as 2 <br />Date: q - 2'g - 1'® �1 <br />1 �lr • .fir•,- t <br />