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SAN JOAQUIN COUNTY <br />IDENVIRONMENTAL HEALTH DEPARTMENT <br />600 East Main Street, Stockton, CA 95202-3029 <br />Telephone. (209) 468-3420 Fax. (209) 468-3433 Web: www.siggy.org�ehd <br />= :11 ov a 11 <br />Any MINOR violations noted in the "Notice to Comply" in the attached inspection report must be <br />corrected within 30 dUs 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 />disv <br />yides to aw,,, violations'. are to <br />unless otherwise specified in the IR. <br />• this certification to be completethe operator • the site must include: <br />A statement <br />i• what corrective actions were taken or will • taken for each violation <br />•• • sample results/manifests/training records/other appropriate paperwork, and/or photos <br />verifying corrections <br />Operator's certification <br />I <br />WMAMIA <br />1. 1 have corrected the violations specified in the Inspection Report from the above-mentioned <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 • true, accurate, and complete: <br />Photos Paperwork Statement <br />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 thi <br />possibility •I a fine and/or imprisonment for • violations. (HSC 25191) <br />Name: Title: <br />Signature: <br />E 22-02-005 Rev 05/07 <br />