Laserfiche WebLink
10/06/2011 08:04 2099316743 Waterloo Food Mart #0720 P.002/015 <br />SAN JOAQUtN 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.si4ov_orci/ehd <br />RETURN TO COMPLIANCE CERTIFICATION <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, HSC 25404.1.2(e)(1) <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 specified in the Inspection Report. HSC 25185(cX3) <br />Note: All EHD staff time associated with failing to comply by the above noted dates will be <br />billed at the current hourly rate. <br />r -.'.r �hi� �.�r}:f:ca�fia�� tv t;rss c..vr: rNlvEv u,v v�o�nlv� yr etre vile Inuaa. tll�.(u�,1C. <br />Ciopica of aamplC rer.r.rrUa/uther appropriate paperwork, anaior photos <br />verifying corrections <br />• Operator's certification <br />Inspection Date: October 4, 2011 Inspected By:Garrett Backus <br />maomEy .tidjs�.s.ft: 4316 E Wn+,=r-ion rZ�c%d cr-^ mPfF. OAL000040 l OT <br />I ...,ss�...-Z--r---' ,..r I_ "--`- <br />1 _ I have corrected the violations speciflud in the Inspection Report from tho above-mentioned <br />inepootion date. <br />?_ I hove peroona{ly sx®minod tho f+�liwv;iy JvvurllesllCraGvrr �utnl,ieEGiS �� prWf oreomplEa>7c� FVK <br />EACH VIOLATION and I believe the information to be true, accul�te, and complete: <br />;/ ,, Photos "Paperwork Statement <br />3_ lam authorized to submit this certification on behalf of the Respondent. <br />4. 1 am aware/that there are significant <br />PossibilitVbf a fine and/or imprisW!1�1 <br />r <br />n <br />nature: d <br />EHD 22-02-005 Rev 09/11 <br />yalttes for submitting false information, including the <br />7t for known violations_ (HSG 25191) <br />Title: <br />Date: <br />'/o/ � <br />