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SAN JOAQUIN COUNTY a <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />600 East Main Street, Stockton, CA 95202-3029 <br />Telephone: (209) 468-3420 Fax. (209) 468-3433 Web: www.siaov.org/ehd <br />144114:111111 `J11, <br />FWAT17111181101M •w2mmuslow•: ` a ••I,, Bff nurn. `• •- mm : =-,talml <br />WiMIMEW1W 210=10a <br />EnTwOmentai neann Alepartment kr_NB77cT*Ure7t5 M Ulfd L*P 01 UIG rumvnnruri 13,11 ClalP New <br />Inspection Report. <br />gitligpMweirlordi III yt,111111111111, 111111111, 1111ril iiiiiiiiiiiiiiiiiiiiiillillilillilIL!Plcpl)lllL!PYM <br />11 1 11 � in 11:1,11 ilf! <br />billed at the current hourly rate. <br />For, this certcation 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 />571WTIFN <br />TTMTT_�� <br />1. 1 have corrected the violations specified in the Inspection Report from the above-mentioned <br />inspection date. <br />Photos Paperwork Statemenl <br />'1 <br />I am aware that there are significant penalties for submitting false information, including tht� <br />possibility of a fine and/or imprisonment for known violations. (HSC 25191) <br />Name: Title: <br />9= <br />EM <br />EHD 22-02-005 Rev 10/09 RETURN TO COMPLIANCE <br />