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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 />11 � RIFIRI, WONZAM I <br />Any MIROR violations noted in the "Notice to Comply" in 1he 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 />Note: All EHD staff time associated with failing to comply by the above noted dates will be <br />billed at the current hourly rate of $105 (beginning 8/11/09 the hourly rate will be $115). <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 cercation <br />I . 0 <br />417MUMITMI-M <br />Inspected By: <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 />nm <br />IWO <br />it I & FLOIN I 111 f] I igel 111 1r,4 11 a to] d j I 101vi lim [01 rt I I m a b-AZI <br />ME <br />EHO 22-02-005 Rev 06/09 <br />"M <br />