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SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />600 East Main Street, Stockton, CA 95202-3029 <br />Telephone: (209) 468-3420 Fax. (209) 468-3433 Web: www.sigoy.orehd <br />"TURN TO COMPLIANCE CERTIFICATION I <br />Mo411014111 I M WOMI'm MIMOVITIMMO M revs I 1=1 a muff IMUM-F, <br />Eke 1"MMET11"I I <br />13 uu-1 <br />177 <br />inspection report. <br />:1 '110 k I <br />vW r1l"WIRMFer I IN <br />7me, 1=011 <br />unless otherwise specified in the IR. <br />For this certification to be completethe 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: Inspected By: <br />Facility Address: EPA ID#: <br />I certify and 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 —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 />Name: Title: <br />Signature: Date: <br />111 11 11 11 1 <br />