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0 SAN JOAQUIN COUNTY 0 <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />600 East Main Street, Stockton, CA 95202-3029 <br />Telephone: (209) 468-3420 Fax. (209) 468-3433 Web: www.sjgoy.org�eh <br />1 :1 By Ito] ofil" 1 111,11,1111 111'� 1 1►11 1111 IN i� , 1 01 ta W 101 14. 0 <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 35 days of receipt of the <br />Inspection Report. <br />(tispules to any VIRMign's, are to 6e SLUMILLCU W <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 billed at <br />the current hourly rate ($98). <br />Mel Relm, URAWM <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 />=63333M <br />Gsmyj�� <br />nXTE mi <br />RMOTTEMM <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 be true, accurate, and complete: <br />. . I <br />11��11111�iqrrir <br />4pgrMIN•T <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 2519 1) <br />Name: Title: <br />2MEM <br />EHD 22-02-005 Rev 11/07 <br />no <br />