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9 SAN JOAQUIN COUNTY 0 <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />600 East Main Street, Stockton, CA 95202-3029 <br />F_XMiXAIhN01" * ppiMmumms is, m. u, u- ow.m. ma i , in n- i un i mr, i mm T-ity Lgo x a ri a - <br />� y'vilaTimax.: <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 />A-5Y1F1Wfi'VNx-WfT-Me associ MP <br />billed at the current hourly rate. <br />i <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 />MAI= <br />1. 1 have corrected the violations specified in the Inspection Report from the above-mentioned <br />.- <br />•- on date. <br />Inspected By: <br />i f WE 0 -0. sees oils <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 />Signature: D. <br />EHD 22-02-005 Rev 08/08 <br />