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91 SAN JOAQUIN COUNTY 4 <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.oLg/ehd <br />Any •' violations noted in the • to Comply" in the -• Inspection Report must •- <br />corrected within 30 •_ of receipt • this inspection. This certification • must • submitted to the <br />Environmental Health Department (EHD) address at the top of this form within 30 days of receipt of the <br />Inspection '_r• <br />All corrections to other violations -noted in the attached Inspection Report (IR) or Continuation,Form, 0 <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 />kip IN- , 6 <br />6111 nE ZWOI &I 1RIF1 1111111 ITj I tell I i KA F1rWTfl I I • 1k M <br />For this certification to be completethe operator • 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 />• Operatces cercation <br />712r, M <br />Inspected By: <br />1. 1 have corrected the violations specified in the Inspection Report from the above -mention <br />inspection date. I <br />• •• • • • . - • <br />Photos Paperwork Statement <br />�MFITW7TMTt*TMVT*Fr*TM7#MM KEZWM=� <br />Name: <br />Signature: <br />EHD 22-02-005 kbv 06/09 <br />ALSFIC A1111619 [_*0111 I liz-3116 cold 41191, 11vj1*1n1q1*1w=j� <br />Title: <br />ma <br />