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San Joaquin County 10 <br />10�nvironmental Health Department <br />1868 East Hazelton Avenue, Stockton, California95205-6232 <br />Any MINOR violations noted in the "Notice to Comply" in the attached Inspection Report must be corrected within 30 days of <br />receipt of this inspection. This certification form must be submitted to the Environmental Health Department(EHID) address <br />at the top of this form within30 days of receipt of the Inspection Report. HSC 25404.1.2(c)(1) <br />Inspection Report- HSC 25185(c)(3) <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-or 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 resultstmanifests1training recordslother appropriate paperwork, and/or photos verifying <br />corrections <br />1111-161golU-14 -- <br />E,EPA 111. <br />Facility Address: Y M FE <br />2. 1 have personally examined the following documentation submitted as proof of compliance FOR EACH VIOLA <br />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 possibility of a fine <br />and/or imprisonment for known violations. (HSC 25191) <br />Um <br />Signature: Date, <br />