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SAN.JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 600 East-Main Street, Stockton, CA 95202-3029 <br /> Telephone:(209)4683420.Fax:(201x)46'8=3433 Web: .s' ov.or / Md <br /> RETURN TO 'COMPLIANCECERTIFICATION <br /> Any MINOR violations noted in the".Notice to Comply" in the attached Inspection}Report'must 6e <br /> corrected within 30 dam of receipt of this inspection. This certification form must.be s,ubrnitted to the <br /> Environental Health Department(EF(D) address at the top of..this form within 30 days of receipt of the <br /> m <br /> Inspection Report. <br /> All c2rrect'ons Lo other violations noted in the attached Inspection Report (IR) or Continuation f=orm,:or <br /> disputes to any violations, are to be says <br /> ubmitted using this certification and returned to EHD <br /> disputes <br /> d <br /> unless otherwisespecifiedin the In"ction Report, _ <br /> Note: All EHD staff time associated with falling to comply by the above noted dateis will be <br /> billed at the current hourly rate. <br /> For this certification. t0 Ike Complete the operator of the.sito:muet include: <br /> . A statement documenting what corrective actions were taken or will be taken for each violation <br /> • Copies of sample.resultslmanffests/training records/other appropriate paperwork, and/or photos <br /> verifying corrections <br /> . Opsrator's cert cation <br /> Inspection Date:�r�� <br /> Inspected'fly: C• ' <br /> .a <br /> Facility Address: EP&[D#:, <br /> certify under penalty of law that: <br /> 1. - <br /> ,I-have-corrected the violatiosp$cified in the Inspectior�Report.from the above-mentioned <br /> r►s <br /> inspection date. <br /> 2. 1 have personally examined the.following documentation submitted as.proof of oompGehee FOR <br /> EACH VIOLATION and I believe the information to be true, accurate, and complete: <br /> ,Photos _Paperwork Statement <br /> 3. 1 am authorized to submit this certification on behalf of the Respondent. <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 /> Title; l CQ �' L�j <br /> Name: <br /> I Date: <br /> Signature. - <br /> EHD 22-02-005 Rev 10100 <br /> ZO 'd 9V:Sl OIOZ cZ Inr O16199b60Z :X6J ]Qd 10 NVA <br />