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0 SAN •,N • <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />600 East Main Street, Stockton, CA 95202-3029 <br />0 <br />A <br />Any •' violations noted in the "Notice to Comply" in the -• Inspection Report must •- <br />corrected within 30 • • receipt • this inspection. This certification form must • submitted to the <br />Environmental Health Department (EHD) address at the top of this form within 30 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 •- submitted using this certification and -• I• EHD within 30 • <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 <br />billed at the current • rate. <br />For this certification to be completethe 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 certcation <br />EMEM3303 <br />USMSMLL-=- <br />I certify under penalty of law that: <br />Inspected By: <br />1. 1 have corrected the violations specified in the Inspection Report from the above-mentioned <br />inspection date. <br />I <br />1111111111111101141 moNvIvej Wad 091 ROWN 911f; <br />Name: <br />Signature: <br />EHD 22-02-005 Rev 10/09 <br />,Photos Paperwork Statement <br />mill 1011AN IIIIIJAR� <br />ffil m <br />Im <br />no <br />