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0 SAN JOAQUIN COUNTY 40 <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />304 East Weber Avenue, P Floor, Stockton, CA 95202-2708 <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 Web. www.sjgov.orgLehd <br />i <br />9 By Fill i 1 ii i I•1 1111 1 114 [41CA0111111 <br />Any MINOR violations noted in the "Notice to Comply" in the attached inspection report must be <br />corrected within 30 dgys 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 (IR) or Continuation Form, or <br />tis?)Tttes t+ arrf YitiIa6rns, ar"i, )re sy•rnittoi7tsinj Us ce-Aificatiirri at -it retwiTioi t+ EEW'withir, f,*, fas <br />unless otherwise specified in the IR. <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 />RTIIITTW71�. - <br />I certify under penalty of law that: <br />1. 1 have corrected the violations specified in the Inspection Report from the above-mentionj <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 />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 />9= <br />Title: <br />LM <br />