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0 SAN JOAOUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />600 East Main Street, Stockton, CA 95202-3029 <br />Telephone: (209) 468-3420 Fax. (209) 468-3433 Web: %vN"v.sjgov.org/ehd <br />I � ZA 0 IN I IL 11 IS- I <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 />u t:TazTwf Vio f*rK=-Lt*in 35 daps Qf receiLsit 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 ReporL <br />Note: All EHD staff time associated with failing to comply by the above noted dates will be billed at <br />the current hourly rate ($98). <br />11 11!111111111111�1q� 1111111 111111111111 1� <br />'111111 2W =10 <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 />Inspection Date: Ir <br />Facility Address: <br />HEMEMM <br />Z, le <br />Inspected By:—��'-� <br />p��pipivsq��11 %T�� I I <br />I jij� I, I <br />2. 1 have personally examined the following documentation submitted as proof of compliance FOR <br />E,O,.CH VIOLATION and I believe the information to be true, accurate, and complete: <br />'TKTPaperwork Statement <br />3. 1 am authorized to submit this certification on behalf of the Respondera <br />4. 1 am aware that there are significant penalties for submitting false information, including t <br />possibility of a fine and/or imprisonment for known violations. (HSC 25191) 1 <br />4 <br />Name: -• Title. <br />Signa re: Date: <br />