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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 />zm��Frlxliirgw . . I <br />- I [Ir Yi��Jpq-34:111 F33 -WL -6 feryFA-11711-LY IT receipi OT ME <br />Inspection Report. <br />Note: All EHD staff time associated with failing to comply by the above noted dates will be <br />billed at the current hourly rate ($105). <br />For this certification to be completethe 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 certification <br />FMM�r� <br />lxnamm <br />I certify under penalty of law that: <br />Ai♦ 3 <br />1 - I have corrected the violations specified in the Inspection Report from the above-mentioned <br />inspection date. <br />11 0 00 0 01 0 <br />Photos Paperwork Statement- <br />;jp�!Iiiir <br />4. lam 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 />Name: <br />Signature: <br />EHD 22-02-005 Rev 08/08 <br />fim <br />no <br />