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0 0) <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />600 East Main Street, Stockton, CA 95202 <br />Telephone: (209) 468-3420 Fay (209) 468-3433 Web. www.si-aov.orgJehd <br />1114311 <br />r , �r • <br />Any MINQR violations noted in the "Notice to Comply" in the attached inspection report must be <br />co wift 20 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 35 days of receipt of the <br />inspection report. <br />All gggpGhM 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 W days <br />unless otherwise specified in the IR. <br />For this certification to be complete the 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 />Facility Address: • <br />I certify under penalty of law that: <br />- corrected t i-violationsspecified 1- f , theInspectioni•above-mentioned <br />inspection date. <br />9d. r: ":`r is ::i...i �i. 1 �... � rr <.: rI `. r .#r` • rb ! rl. ♦ �'' <br />Photos Paperwork <br />Name: Title: <br />M <br />