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SAN JOAQUIN COUNTY 9 <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />600 East Main Street, Stockton, CA 95202-3029 <br />- - Telephone: (209) 468-3420 Fax. (209) 468-3433 Web:. •sioov.or /� ehd _ <br />Any MINOR violations noted in the "Notice to Comply" in the attached Inspection Report must be <br />corrected 0 days of receipt • •..:' • : - This certification'.:• •... submitted •. 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 violationsi _•:.. in the attached Inspection Report .:.. or Continuation • or <br />billeddisputes 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 />Note: All IEHD staff time associated with failing to'comply by I the above noted dates will be <br />at the currenthourly <br />verifyingFor 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 />corrections <br />9 Operator's certification <br />i <br />AgAt1j"i <br />I certify under penalty of law that: <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 />Name: <br />Signature: <br />EHD 22-02-005 Rev 10/09 <br />Title_. . <br />- Date: <br />