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Au,. ,18 11 12:49p Bos—Access 209 333 0318 <br />4( Bf2411 THU 6:37 FAX ZU!04+®c 001- <br />11- <br />002454 <br />SAN JOAQUIN COUNTY <br />ENV:RONMENTAL HEALTH DEPARTMENT <br />600 East Main Street, Stockton, CA 95202-3029 <br />Tefog'.One: (209) 4ge-3420 Fax: (209) 468-3433 Web: w_w_w__s1J%0_v._0%V_8hd <br />y 0 • c <br />Any MINOR violations noted in the "Notice to Comply" in the attached Inspection Report must be <br />corrected within 39 ftMs of receipt of this inspection. This certification form must be submitted to the <br />Envilronmontal Health Department (EHD) address at the top of this form within 30 days of receipt of the <br />inspection Report. <br />All co ffggions to o her victaMOM noted in the attached inspection Report OR) or Continuation Form, or <br />disputes to any violations, are to be submitted using this certification and returned to EHD within 30 dans <br />unless otherwise specified In the Inspection Report. <br />Note: All EHD staff time associated xith failing to comply by the above noted dates will be <br />billedat the. cu merit. haurly..r a. . . ............ . _ .......... _.... _ ...... .. <br />For this certification to be complete the opimtor of the site must Include: <br />• A statement docume what corrective actions were taken or will betaken for each violation <br />• Copies of sample resuits/manifests/training recordsiother appropriate paperwork, and/or photos <br />verifying corrections <br />Inspection tate: ? �� <br />Facility Address: (610`' <br />I certify under penalty of lav that <br />1, I have corrected the violations specified in the Inspection Report from the above-mentioned <br />inspection date. <br />2. 1 have personally examined the following documentatlon submitted as proof of compliance FOR <br />EACH VIOLATION and I believe the1nformadorr to be true, accurate, and complete: <br />Phatos PaperworkStatement <br />3. lam authorized to submit this certification on behalf of the Respondent. <br />4 1 am aware that there are significant penalties for submitting false information, including the <br />possibility of a fine arxUar imprisonment for known violations. (HSC 25191) <br />Name' <br />`/ - SJ,� 1-/ rale: i��p <br />nature - <br />Ee0 22.02-M ROM OTs <br />M3 <br />p.2 <br />