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SAN JOAQUIN Co <br />600 East Main Street, StDckton, <br />Tekpkone. (209) 468 -*0 A�a (209)468-2, <br />C <br />ARTMENT <br />95202-3629 <br />Web. mrq �.sov.�orehd <br />it 0 4 M I ll <br />lf*gii <br />1� it'r Q <br />-1 attached inspection Report must be <br />ification form must be submitted to the <br />'this form within 35 days of receipt of the <br />ion Report (IR) or Continuation FoM or <br />2ation and returned to EHD ithin 30 days <br />�jt �- <br />Itor of the site must include: <br />taken oft will be taken for each violation <br />.er appropriate paperwork, and/or photos <br />Inspection Date: <br />inspected <br />Facility Address: (o (45-7 E ID <br />�A #: <br />I certify under penalty of law that: <br />I - I have corrected the violations specified in the Inspecti]I on Repoi <br />inspection date. <br />2. 1 have personally "amined the following documentation submi <br />EACH VIOLATION and I believe the information to be true, as <br />-Photos Yaperwork V1 <br />3. 1 am authorized to submit this certification on behalf of the Resl <br />4. 1 am aware that there am significarrt`penalties for subinitting fal.- <br />PossibilityAa fine and/or imprisonment for known violation._ 1 <br />: A-yzL n -s <br />from the above-mentioned <br />as proof of compliance FOR <br />tte, and complete: <br />'ement <br />ent. <br />> r__ <br />JUN 2 3 2011 <br />SAN ."JUNTY <br />HEALTH D'-EF'1i',,T?AENT <br />