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r 0 0 RECEIVED <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT MAY 2011 <br />600 East Main Street, Stockton, CA 95202-3029 t <br />Telephone: (209) 468-3420 Far. (209) 468-3433 Web: www.sjgoy.orgLehd <br />EWRONMENTAL <br />PERM11298WES <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 ($122). <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: �5/2(V % l' _ Inspected By: Stacy Rivera <br />M t LA rn 4-t 1 <br />Facility Address: 1 b 0 S' FL �`�"" EPA ID#: C <br />( <br />I certify uncle nalty of law that: a 5r <br />Ol I have corrected the violations s cif in the Ins ection Rep oln� above-mentioned <br />i spection date. <br />.-C-3 --e' n <br />2. I 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. I am authorized to submit this certification on behalf of the Respondent. <br />4. I 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: ,�3 A t- ,A -3 - —A) 61 LIC <br />EHD 22-02=005 Rev 08/10 <br />Title: <br />Date: s -T y 7 I i <br />