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SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />304 East Weber Avenue, Yd Floor, Stockton, CA 95202-2708 <br />Telephone. (209) 468-3420 Fax. (209) 468-3433 Web: www.sjgov.or_gJ <br />19 M <br />0=0 <br />inspection report. <br />All corrections to other violations noted in the attached Inspection Report (IR) or Continuation Form, or <br />-fisputes to any violations, are to be submitted using this certification and returned to EHD within 60 day� <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 />9 Operator's certification <br />FFIM-MR173�. _ <br />GM=15[m <br />I certify under penalty of law that: <br />IV M TOM rtl= <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 Statemen! <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 />RPM <br />1:01 <br />Title: <br />LM <br />