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SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH 4DEPARTMENT 1 868 East Hazelton Avenue, Stockton, California 95205-6232 <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 Web, MMM.sjgov.org/ehd <br />a A - <br />Any Ml OR 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 30 days of receipt of the <br />Inspection Report. HSC 25404.1.2(c)(1) <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. HSC 25185(c)(3) <br />Note: All EHD staff time associated with failing to comply by thPA"Uk+j. be <br />billed at the current hourly rate. <br />JUN 0 6 20114 <br />For this certification to be complete the operator oft in Jude: <br />• A statement documenting what corrective actions were taken or will b! <br />T r L <br />• Copies of sample results/manifests/training records/other appropriate %p'1W&%TVff6f0S <br />verifying corrections <br />• Operators certification <br />Inspection Date: May 7, 2014 inspected By:StaCY Kivera <br />• <br />msm��13 <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 v1 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 />P.. <br />Name: Q04 e -A_ DjrTfl-A— Title: ?ifZEtTOa 6F 6:;AJ%4*UA//4WrA7_ <br />In A mm W(.X1- 1�raP MA-f.LWEIrS, <br />Mr. <br />EHD 22-02-005 Rev 04119/12 <br />Date: &I&tt <br />R <br />