Laserfiche WebLink
Al 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.siaov.o[g/ehd <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 />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 />-]I I 1:g --11 IN VA jrtjC-X*j W;j11 r;K;jhFL1F-jk4 <br />mi <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 certcation <br />117777TUM <br />mmo <br />Inspected By: <br />1. 1 have corrected the violations specified in the Inspection Report from the above-mentio n <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 />III ;pi�, <br />4. 1 am aware that there are significant penalties for submitting false information, including tl-� <br />possibility of a fine and/or imprisonment for known violations. (HSC 25191) 1 <br />Title: <br />ma <br />EHD 22-02-005 Rev 06/09 <br />