COMPLIANCE INFO_PRE 2019 - Laserfiche WebLink

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San Joaquin County Environmental Health Department 1868 East Hazelton Avenue, Stockton, California95205-6232 Telephone: (209) 468-3420 Fax: (209) 468-3433 Web:www sigov org/ehd RETURN TO COMPLIANCE CERTIFICATION Any MINOR violations noted in the"Notice to Comply" in the attached Inspection Report must be corrected within 30 days of receipt of this inspection. This certification form must be submitted to the Environmental Health Department(EHD) address the top of this form within 30 days of receipt of the Inspection Report. HSC 25404.1.2(c)(1) All corrections to other violations noted in the attached Inspection Report(IR) or Continuation Form, or disputes to any violations, are to be submitted using this certification and returned to EHDwithin 30 days unless otherwise specified in the Inspection Report. HSC 25185(!)(3) th failing to comply by the above noted dates will be Note: All EHD staff time associated wi billed at the current hourly rate. For this certification to be complete, the operator of the site must include: A statement documenting what corrective actions were taken or will be taken for each violation Copies of sample resultstmanifests1training records/other appropriate paperwork, and/or photos verifying correction! Inspected By: NICHOLAS LOEHRER Inspection Date: EPA ID: Facility Address: I certify under penalty of law that: 1. I have corrected the violations specified in the Inspection Report from the above-mentioned inspection date. 2. 1 have personally examined the following documentation submitted as proof of compliance FOR EACH VIOLATIO I believe the information to be true, accurate, and complete: Photos Paperwork Statement 3. 1 am authorized to submit this certification on behalf of the Respondent. 4. 1 am aware that there are significant penalties 251 for submitting false information, including the possibility of a fine and/ imprisonment for known violations. M ) Title: Name: Date: Signature: