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0 <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />600 East Main Street, Stockton, CA 95202-3029 <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sigov. <br />Q14d4ES)48?4# =49WRIM68 <br />WWOWN ITIOW-roffroxis <br />ymp <br />& L1 I L 1L11111.3J UWl M moic <br />inspection report. <br />oil <br />'Rnm=1 ITT" <br />IN <br />unless otherwise specified in the IR. <br />For this <br />® to be complete the operator oft e 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 certification <br />cmmiz�� <br />1. 1 have corrected the violations specified inthe Inspection Report from the above-mentioned <br />inspection date. <br />2. 1 have personally examined the following documentation submitted as proof of compliance FOIN <br />EACH VIOLATION and I believe the information to be true, accurate, and complete: I <br />.Photos Paperwork Statement <br />4 <br />T. I 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 2519 1) <br />Name: Title: <br />a <br />1111111111 111 1 - I <br />