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0 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.sogov.org/ehd <br />Any MINOR violations noted in the "Notice to Comply" in the attached Inspection Report must •- <br />• - -• <br />eorrected 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 />Mote: All EHD staff time associated with fang to comply by the above noted dates will be <br />billed at the current hourly rate. <br />or 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 />amn, = RIM- <br />m3m <br />Inspected By: <br />1. 1 have corrected the violations specified in the Inspection Report from the above-mentionri <br />inspection date. <br />0 ow F - 0- <br />K91111911 -A -A - <br />KTA Lei WIN NVOR, IF115im MeNW47144AU-1111156i 11IR141011 nvololr-�ZAI is MKI E��� <br />Photos Paperwork Statement <br />I <br />I am aware that there are significant penalties for submitting false information, including ti <br />possibility of a fine and/or imprisonment for known violations. (HSC 25191) <br />MW <br />EHD 22-02-005 Rev 10/09 <br />Title: <br />as <br />