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E <br />C <br />San Joaquin County <br />Environmental Health Department <br />1868 East Hazelton Avenue, Stockton, California 95205-6232 <br />Telephone: (209) 468-3420 flax: (209) 468-3433 Web: www.$)go%or /g ehd <br />Any MINOR violations noted in the "Notice to Comply" in the attached Inspection Report must be corrected within 30 day§ of <br />receipt of this inspection. This certification form must be submitted to the Environmental Health Department (EMD) address <br />the top of this form within 30 days of receipt of the 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 disputes to any <br />violations, are to be submitted using this certification and returned to EHD within 30 days unless otherwise specified in the <br />Inspection Report. HSC 25185(c)(3) <br />Note: All EHD staff time associated with failing to comply by the above noted dates will be <br />billed at the current hourly rate. <br />For this certification to be complete, the 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 verifying corrections <br />"nspection D. 04 2016 InspectedMCCARTNEY <br />11j11;j111!1j1;j 1, 1111111 i 11111!1111 111pil!1111111111 !111 1111,11 11��111 111111 ;! !Ili�1111�111111ri 1111 <br />2. 1 have personally examined the following documentation submitted as proof of compliance FOR EACH VIOLATION <br />1 believe the Information to be true, accurate, and complete: <br />Photos -/Paperwork Siatement <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 possibility of a fine and/ <br />Imprisonment for known violations. (HSC 25191) <br />Name:_[10yEt'L l3Ar/Ljj--(j" 0"" Slot Mitrttc lttle: �►�CcTasL Gi- nvirrdaa���•,�itt izf <br />- �7L,AW Date: 6 <br />:AL1 _ <br />