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SAN JOAQUIN COUNTY <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.o[g/ehd <br />Any MI , NOR violatiooted in the "Notice to Comply" inthe attached Inspection Repor I t 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 />Kel us MOO 11 0 0 0 0 00 a 0 0 <br />Note: All EHD staff time associated with failing to comply by the above noted dates will bz <br />billed at the current hourly rate. <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 />311PIP =__7i viii omit <br />6: 0 <br />T.M=, m <br />Inspected By: <br />Ai�.� <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 />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 />nature: Date: <br />EHD 22-02-005 Rev 08/08 <br />