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SAN JOAQUIN COUNTY 0 <br />4kNVIRONMENTAL HEALTH DEPARTMENT <br />304 East Weber Avenue, P Floor, Stockton, CA 95202-2708 <br />Telephone. (209) 468-3420 Fax: (209) 468-3433 Web: www.sjgov.orgLehd <br />191,15i 11 lil,111151111 I 'i lliuziiinii owplltawn 5 <br />Any MINOR violations noted in the "Notice to Comply" in the attached inspection report must be <br />corrected within 30 dgys 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 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 60 days <br />unless otherwise specified in the IR. <br />For this certification to be compTete the operator of the site must include: <br />0 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 />FEW 19MITI =- <br />I certify under penalty of law that: <br />=633� <br />1. 1 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 Paperwork Statement <br />3. 1 am authorized to submit this certification on behalf of the Respondent. <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 />9= <br />Title: <br />