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0 0 • <br />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 />Any MINOR violatlons� 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 t'• of this form wn 30 days of receipt • 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 • the above noted dates will • <br />billed at the current hourly rate. <br />For this certification to be completethe operator of the site must include: .- <br />* A s1atement documenting what corrective actions were taken or will be taken for each violation <br />9 Copies of sample results/manifests/training records/other appropriate paperwork, and/or photos <br />verifying corrections <br />3 K•P1 •3 ^ _ • &-W*rTa (I ff*Twl• <br />Inspection Date: Inspected By: <br />Facility Address: EPA ID#: <br />1. 1 have corrected the violations specified in the Inspection Report from the above-mentioned <br />inspection • <br />t,. I have personally examined the following documentation submitted as proof of compliance FO <br />EACH VIOLATION and I believe the information to be true, accurate, and complete: I <br />Photos Paperwork Statement <br />121--N-jawkeld I I 110111 --fel all L-1116MAJI[My" <br />EHD 22-02-005 Rev 08/08 <br />:11 Uff-TOTITSM <br />km - <br />Date: <br />