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AdL <br />19 SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />304 Past Weber Avenue, 30 Floor, Stockton, CA 9$202-2708 <br />Telephone; (209) 468-3420 Fax: (209) 468-3433 Web: www.sjgov.orLehd <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 />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 60 gas <br />unless otherwise specified in the IR. <br />For this certification to be complete the operator of the site must include: <br />0 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 />-.e <br />Inspection Date: Inspected By:,�a� <br />Facility Address: AL 644�hllAe dg. 1;EPA ID#: Cz�4tbQ0 2,5-9-V7 <br />,537,4 <br />I certify under penalty of law that: <br />1. I 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 Paperwork Statement <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 />Name: j* I Title: <br />Signature: �� ,I Date: <br />RHD 2202-005 Rev 12-04 <br />V 'd E 118'0 N SISHddlIN] HU0 Wt:g 90H 11'JeN ' <br />