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SAN JOAQUIN COUNTY <br />*ENVIRONMENTAL HEALTH DEPARTMENT <br />600 East Main Street, Stockton, CA 95202-3029 <br />Telephone: (209) 468-3420 Fax. (209) 46873433 Web: www.sj&qv.or&hd <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 ths <br />Inspection Report. <br />F."I owl II"I <br />(11spuLes to ally tWe E0 0c; <br />0, <br />unless otherwise specified in the Inspection Report. <br />Note: All EHD staff time associated with fang to comply by the above noted dates will be billed at <br />the current hourly rate. <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 />ffl• -� ; , <br />1. 1 have corrected the violations specified in the Inspection Report from the above-mentioned <br />inspection date. <br />I 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 />1"hotos Paperwork Statemen7 <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 />ME <br />E <br />