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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.sjgov.orgLehd <br />NURN ?III 1"WE -0- " 1 0 11 A 1A V I I 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 formmust be submitted to the <br />Environmental Health Department (EHD) address, at the top of this form within 3 5 days of receipt of thi <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 60 dUs <br />unless otherwise specified in the IR. <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 />1m; <br />1. 1 have corrected the violations specified in the Inspection Report from the above-mentioned <br />inspection date. <br />ftotos -Paperwork Stateme�2_L <br />t. I am 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 and/or imprisonment for known violations. (HSC 25191) <br />"M <br />03 <br />191091 m11mium <br />n <br />