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9 SAN JOAQUIN COUNTY 0 <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />304 East Weber Avenue, 3d Floor, Stockton, CA 95202-2708 <br />Telephone. (209) 468-3420 Fax. (209) 468-3433 Web: www.sigov.or <br />1 .011 DO fill 11 [11 1 1] 1 1 1 1 1 1 ii� i' � � I Wel 51 14"a I � � i <br />FITOM811 I • - •4 1 -4 #_ • I•t 901-� <br />I M -XISTMI <br />M= <br />inspection report. <br />Ilia <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 />WMT019 <br />Inspected By: <br />I have corrected the violations specified in the Inspection Report from the above -mention <br />inspection date. I <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 />12 ME= M_ "N= <br />3. 1 am authorized to submit this certification on behalf of the Respondent. <br />,4 tt <br />I am aware that there are significant penalties for submi ing false information, including the <br />possibility of a fine and/or imprisonment for known violations. (HSC 25191) <br />Name: Title: <br />Signature: <br />M <br />In <br />