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SAN JOAQUIN COUNTY <br />-• HEALTH DEPARTMENT <br />600 East Main Street, Stockton, CA 95202-3029 <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www-sigov.org/ehd <br />10:401 Ci� 11 11,171111 1 ] ` � i, 11 11 ii A*4134:41 � A sk <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 30 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 />disputes to any violations, are to be submitted using this certification and returned to EHD within 30 days <br />unless otherwise specified in the Inspection Report. <br />Note: All EHD staff time associated with failing to comply by the above noted dates will be <br />billed at the current hourly rate. <br />For. this certification to be completethe operator of the 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 />• corrections <br />• Operator's •.' <br />Inspection Date: Inspected <br />Lczoz�� <br />.-MITTA-5 <br />1. 1 have corrected the violations specified in the Inspection Report from the above-mentionet <br />inspection ♦:.. <br />Photos Paperwork Statement <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 />EHD 22-02-005 Rev 10/09 <br />Title: <br />OWT-m- <br />