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02/29/2008 FRI 9:16 FAX 2 83433 SJC EHD 0004/004 <br />SAN JOAQUIN COUNTY <br />LNVIRONMENTALHEALTII DEPARIMENT COPY <br />600 East Main Street, Stockton, CA 95202-3029 <br />Telephone: (209) 468-3420 Firs: (209) 468-3433 Web: www.si_aov.org/ehd <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 30 days <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 billed at <br />the current hourly rate ($98). <br />For this certification t0 be complete tl,c operator of the site must include: <br />0 A statement documenting what corrective actions were taken or will be taken for .ach violation <br />0 Copies of sample results/manifests/training records/other appropriate paperwork, and/or photos <br />verifying corrections <br />• Operator's certification <br />Inspection Date:,. _ _ a Inspected By: -_-V <br />Facility Address: // 0 jQ) _ PA ID#: _ <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. I have personally examined the following documentation submitted as proof of compliance FOR <br />EACH VIOLATION and 1 believe the information to be true, accurate, and complete: <br />Photos L_ra_P_`cn xork Statement <br />3. I am authorized to submit this certification on behalf of the Respondent. <br />4. 1 am aware that there are significant penalties for submitting false infonnation, including the <br />possibility of a fine and/or imprisonment for known violations. (HSC 25 19 1) <br />END 22-02-005 Rev 11 <br />FEE -29-2008 09'46 2094683433 93% <br />P. 04 <br />