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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.sigov.org/ehd <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 thisjorm within 30 days.pf receipt of the <br />Inspection Report. I <br />All corrections to other violations noted i n the attach ed I Inspection Repo rt (I R) or Conti n uation m, 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 Report. <br />Note: All EHO staff time associated with failing to comply by the above noted dates will be <br />bfl[W-atthe Current hourly rate. <br />For this certification to beCOMPlete the operator of the site must include: <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 certcation <br />i W-1111 <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 />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 the <br />possibility of a fine and/or imprisonment for known violations. (HSC 25191) <br />Title: <br />so <br />EHD 22-02-005 Rev 10/09 <br />