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002454 <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />600 East Maim Street, Stockton, CA 95202-3029 <br />Tefep:?one. (209) 468-3420 Feu. (209) 468-3433 Web: www.s ov.ora/ehd <br />a • r <br />Any MINOR violations noted in the "Notice to Com ply" in the attached Inspection Report must be <br />co ed 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 within 30 days <br />unless otherwise speciffied in the Inspection Report. <br />Note:D staff time associated vAth failing to comply by the above.c_ •. dates be <br />billed at the current hourly rate. <br />For _ • : to be o; f <br />operatorof -must include: <br />• A statement documenting what correctivie actions were taken or will be taken for each violation <br />• Copies of sample <br />,..• _resufts/manifests/trainingrecordslotherappropriate paperwork,and/orphotos <br />verifyingcorrections <br />F1IT-F Iim <br />Inspection t c, . Inspected :: <br />t <br />underI certify <br />1. 1 have corrected the violations specified in the Inspection Report from the above-mentioned <br />inspection date. l;)9c cAi- {•-►r ZA-r"1 -01 4A -h I%A. <br />2. 1 have personally examined the following documentation submitted as proof of compliance FOR <br />EACH VIOLATION and I believe the,informatiorrto be true, accurate, and complete: <br />Photos V Paperwork V Statement <br />3. 1 am authorized to submit this certification on behalf of the Respondent. <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- o dci H. a r r,, Title: Lte� ®n`c- ( E A V. VNA nvs c 0 - <br />Signature, 4j Date, � � � 03, <br />EHD 22.02.005 Rev 085 <br />