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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.sigov.org/ehd <br />ili'i 11, 11111 111 NO` I 117lii I ::K4j:t;• <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 />Note: All EHD staff time associated with failing to comply by the above noted dates will be <br />billed at the current hourly rate. <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 />a Copies of sample results mani est raining reco s ot er appropr ate paperwor , an or p otos; <br />verifying corrections <br />* Operator's certification <br />B;rm=, mm <br />-33M <br />Inspected By: <br />MW <br />1. 1 have corrected the violations specified in the Inspection Report from the above-mention,�V-9 <br />inspection date. I <br />Photos Paperwork Statement <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: Title: <br />H= <br />EHD 22-02-005 Rev 10/09 <br />