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FROM FAX NO. :2093699162 jdphptc,."92"2009-10:16AM P2 <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENY- <br />600 East Main Street, Stockton, CA 95202-3029 <br />Telephone. (209) 468-3420 FAX. (209) 468-3433 Web. WWW.SigoV.oEg/ehd <br />III 11111� I ; ; I � <br />F47• <br />Any MINOR violations noted in the "Notice to Comply- in the attached inspection Report must be <br />corrected within 30 dgys_ 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. <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 da*vs <br />unless otherwise specified in the Inspection Report. <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 of $105 (boi6ning 811/09 the hourly rate, will be $115). <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 <br />verifying corrections <br />Operator's certification <br />Inspection Date: k� Inspected BY: <br />'—.-%t EPA ID#: <br />Facility Address: 2 4 1-9 W <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 is proof Of compliance FOR <br />, personally examined the following documentation submitted c , <br />EACH VIOLATION and'I believe the information to be true, accurate, and complete'. <br />Pho . tos I --'Oap,e.rw6rk _LzStatem''Ont <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 imprison.ment for known violations. . (HSC 25191) <br />Name: G'714tjAA Title- 0'-;) <br />Date: 04 <br />EM 22-02-M R" WM <br />