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SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMERN <br />600 East Main Street, Stockton, CA 95202-3029 <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.siaov.ora/ehd <br />[44 A I • <br />I a <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. <br />All corrections to other violations noted in the attached Inspection Report (IR) or Continuation Form, or <br />im kexmW�_n-�_to be submitted usin•this certification and returned to EHD within 30 daws <br />unless otherwise specified in the Inspection Report. <br />Note: All EHD staff time associated with failing to comply by the above noted dates will be <br />billed at the curren t hou rly rate of $105 (beginning 8/1/09 the hourly rate will be <br />or this certification to be completethe operator of the site must include: <br />• A statement A ocu menting 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 />Inspected By: <br />1. 1 have corrected the violations specified in the Inspection Report from the above -mention !1T <br />inspection date. I <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: <br />Signature: <br />EHD 22-02-005 Rev 06/09 <br />Wo <br />LW <br />