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• <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT SEP 19 2013 <br />600 East Main Street, Stockton, CA 95202-3029 <br />(209) 468-3420 Fax: (209) 468-3433 Web. www,§i!jov.arg1 NviRONMENTAL HEALTH <br />PERMITISERVICES <br />TO COMPLIANCE CERTIFICATION <br />Any MINOR violations not in the NNotice to Comply" in the attached Inspection Report must be <br />corrected within 30_days of eceipt of this inspection. This certification form must be submitted to the <br />Environmental Health Depa tment (EHD) address at the top of this form within 30 days of receipt of the <br />inspection Report. HSC 25,104.1.2(c)(1) <br />All corrections to other violaions noted in the attached Inspection Report (IR) or Continuation Form, or <br />disputes to any violations, a e to be submitted using this certification and returned to EHD within 30 days <br />unless otherwise specified in the Inspection Report. HSC 25185(c)(3) <br />Note: All EHD staff tim�associated with failing to comply by the above noted dates will be <br />billed at the curt t hourly rate. <br />For this certification t0 be Complete the operator of the site must include: <br />• A statement document(ng what corrective actions were taken or will be taken for each violation <br />• Copies of sample resins/manifestsltraining records/other appropriate paperwork, and/or photos <br />verifying corrections <br />• Operator's certification <br />Inspection Date: &1 Cv S t- 0qdF o20 13 Inspected By: Stacy Rivera <br />Facility Address: 10 17 W - 1" KC MONr- Sj. EPA ID#: CA -L a0 na S'7 "79 <br />S1r0 U, -'t del , C er <br />I certify under penalty of law that: <br />1. 1 have corrected thQ 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 X 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 />S I't V 6 L,S Title: Cf" 2.oniM G"fAL C.O <br />IAM <br />Date: `5 /19 �C- <br />13 <br />[HO 2402-0051 Rev 09111 <br />