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6 <br />E <br />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.skjov.gMLehd <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 specified in the Inspection Report. <br />Note: All IEHID staff time associated with failing to comply by the above noted dates will be <br />billed at the current hourly rate. <br />W- <br />.�-or this certification to be completiethe 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, andlor photos <br />verifying corrections <br />• Operators certification <br />Inspection Date: Inspected By:_M -ir� 4-f t: tz -t_- <br />Facility Address: <br />�74 <br />I I 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 —�Z—Paperwork —4—Statement <br />1710=0457-77 M <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: <br />EHD 22-02-M 116V 10109 <br />W. M <br />