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SAN.JOAQUIN COUNTY .; <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 600 East Maui Stmt, Stockton, CA 96202-3028 <br /> =343$.Web: <br /> Telephone;(209)468 $420•FAX;(209)'468 �iaov_orcleMd <br /> T I I �IC I. <br /> Any MIN violations noted in the"Notice to Comply' in the attached Inspection-Report,must bs <br /> correct withi' 3d d 's of receipt of this inspection. This certificationm W hin 30 days of 6cmust,be eipt of he <br /> Environmental Health Department(AHD) address at.the top af.thls form. <br /> -Inspection Report. <br /> All rrect'ons o 0th r viol tions noted in the attached Inspection Rand(returned t®tEHaw�tForm <br /> n 0 d r� - <br /> disputes to any violations, are to-be submitted using this certification <br /> unless otherw ise-specified in the Inspection Report. _ <br /> Note: All HD staff time a ociaxed with'falling to comply by thea ve nota dates will bs <br /> billed at the current hourly rate. <br /> Fo <br /> I' I certification-t0 CoMplete the opo tor:.0-tho.ske:•mu0t 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 p. os <br /> verifying corrections <br /> • Operator's cert cation' <br /> . .. �; '49- <br /> In� 'ection Date: Inscted' y <br /> ,��� .J? <br /> °EPA.[ <br /> Facility Address:J,2. � • <br /> 1 certify under penalty of law that: <br /> 1. .:I.have.corrected the viala�orjs.specified In the Inspection-Report.from the'above-m®rationed <br /> inspection date. <br /> 2. 1 have personally examined thefollowing 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 /> 1 am authorized to submit this certification on behalf of the Respondent. . <br /> . 1 am aware that there are significant penalties for submitting false information,.including the <br /> possjbility of a fine and/or imprisonment for known violations. (HSC 25191) <br /> es <br /> Name: <br /> Title: ... - - <br /> Date: <br /> Signatur8:�.� - <br /> EHD 22-02-005 Rev 90109 <br /> ZO 'd 9V:5L OLOZ 0Z Inr 0L6L99V60Z:Xej 10d 30 NVA <br />