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rl <br />I <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />600 East Main Street, Stockton, CA 95202-3029 <br />Wry <br />I 111] 51111 i'I 1 1,11"11 MW OR 0 <br />Any MINOR violations noted in the "Notice to Comply" in the attached inspection report must be <br />corrected within 30 dqys 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 35 days of receipt of the <br />inspection report. <br />unless otherwise specified in the IR. <br />For this certification to be completethe operator of the site must include: <br />0 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 />Iff"INTWITIUM <br />10 91,119 1 <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 StatemeiM <br />''! 'i �11'� "I I l• r . i• <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 />Name: Title: <br />om <br />i ill 11 11 i I <br />