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r,, <br />4652296 <br />WILSON&COFFEY ADPL. <br />SAN JOAQUIN COUNTY <br />FNWRONMENTAL HEALTH DEPARTMENT <br />304 East Weber Avenue, 3rd Floor, Stockton, CA 95202-2708 <br />irnne: (209) 468-3420 rax. (209) 468-3433 Web: www._sjgov qM/ehd <br />ETRN TO COMPLIANCE CEIi'I'IFICATION <br />PAGE 01/02 <br />Any MTNOR violq.ti.ons noted in the "Notice to Comply" in the attached inspection, report must be <br />corrected within 3 da s cf receipt of this inspection. This certification form must be submitted to the <br />Environmental. Health Depaitment (F,,HD) address at the top of this form. within 35 clays of receipt of the <br />inspection report. <br />All corrections to Dther vi lations noted in the attached Inspection Report (IR) or Contix.uation Form, or <br />disputes to any violations, are to be sttbinitted using this certification and returned to EHD within 60 da s <br />unless otherwiseecifie in the TR. <br />For this cer <br />e A statem( <br />s Copies of <br />verifying <br />s (")n�rfltnr' <br />Inspection <br />l.li ca 10x.1 to be COX PICte the operator of the site must include: <br />nt doeu enting what corrective actions were taken or will be taken .for <br />. each. violation <br />sample .results/rnatyifc,sts/training records/other appropriate paperworkand/or photos <br />Certi fi cation <br />'314?,D A� 7 <br />Facility Addre�s:" -� ..SQ. <br />Inspected By: D3z <br />EPA ID #: <br />T certify under penall y of law that: <br />L T have co rocted the violations specified i.n. the Inspection Report from the above-mentioned <br />insnectio i date. <br />2. 1 have ptLATtON <br />nall.examined the following documentation submitted as proof o.f. compliance FOR <br />EACH I and.( believe the information to be true, accurate, and complete: <br />3. T am autliori7ed <br />4. T am aw#e that <br />possibili ty of a. <br />Name: 4 �)r <br />_>_C_Pllotos _Paperwork Statement <br />submit this ccrti..ffication on behalf of the Respondent. <br />e are si,gni fi.cant penalties :for submitting false infortn.ation, including the <br />and/or imprisonment for lctiown violations. (.H.SC 25191) <br />SiLmature: ^ j „ _r\, .�-� Date: <br />