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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.sigov. <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 />A•I&AWENIF-Emil Airum 2F&7Mig,*f <br />inspection report. <br />111!111: 1 111 1 1 1� ; 1�11111iil 111�1111111�1 11,11111 11;1�� 1;1�11 11[i ill) 1110 4) <br />aispi-tes to 113.1 1,11111111nis, are to oe suonlittea using I'lis certification NO retumm toEAl—iWiMi—nbil, Rays <br />unless otherwise specified in the IR. <br />For this certification to be completethe 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 />[MUM <br />Inspected By: <br />1. 1 have corrected the violations specified in the Inspection Report from the above-mentionei <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 Paperwork Statemea <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: Title: - <br />M <br />EHD 22-02-005 Rev 15/07 <br />