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SAN JOAQUIN COUNTY Ah <br />ENVIRONMENTAL HEALTH DEPARTMEW <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 this form within 30 days of receipt of the <br />Inspection Report. <br />All corrections to other violations noted in the attached Inspection Report (IR) or Continuation Form, or <br />disputes to any violations, are to be submitted using this certification and returned to EHD withiri -30 days <br />unless otherwise specified in the Inspection Report. <br />Note: All EHD staff time associated with failing to comply by the above noted dates will be <br />billed at the cu - rrent ho - url . y'rate of $105 (beg- inniing 8/1/09 the hoUrIly rate 'Will be $115). <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 />FZ�111=� <br />M -M <br />TIT-TIT-y9mm <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 />-3. 1 am -authorized to submit this certification on. behalf of the, Respondent. <br />4. I'am aware thattherei are Significant penalties for submitting- false information, including the <br />possibility- of a fine and/or -imprisonment for known violations. (HSC 25191) <br />EHD 22-02-005 Rev 06/09 <br />Title: <br />Date: <br />