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0 0 <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />1868 E. Hazelton Ave., Stockton, CA 95205-6232 <br />Telephone. (209) 468-3420 Fax. (209) 468-3433 Web: Nvww.sjgov.orgLehd <br />11,114, 10 <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 or Continuation Form, or <br />disputes to any violations, are to be submitted using this certification and returned to EHI) within 30 days <br />unless otherwise specified in the Inspection Report. <br />Note: All ERD staff time associated with failing to comply by the above noted dates will be billed at <br />the current hourly rate ($125). <br />I I <br />041011M 1 1111 <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 />I certify under penalty of law that: <br />1. 1 have corrected the 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 I/ Statement <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 />Name:— Title: <br />Signature: Date: -;5- <br />