Laserfiche WebLink
x)q Mry 'Nn.�OH.SIK,rNVNv.-..1 Y.r.:. >'.fy—v-.• 1R — <br /> W rV3+ M 9cv <br /> s9NJoaaulRC.PUNTr <br /> ENVIRONMENTAL HFIILTH Dt?AR1tNLJi;" <br /> 600 East Maln Street;St6ckti�ti;CA 95202-3029 <br /> Te/epborre:(209)488-3420 Fax:(209)468.3433 Wap: .J9ov.os' r !e " <br /> x ✓yO�N <br /> RETURN TO COMPLIANCE CERTIFICATION <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 F� "' • ;` <br /> Inspection Report. <br /> a : {:•. <br /> Allcorreotiona 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 dsys,A,i1 .. <br /> unles*otherwise specified in the Inspection Report: I , <br /> Note: All EHD staff time associated with failing to comply by the above noted dates will be <br /> hilted at the current hourly rate. K ;; <br /> For this certification t0 be Complete the 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 resultslmanifests/training records/other appropriate paperwork, andfor photos <br /> verifying corrections <br /> • Operator's certification <br /> Inspection Data: .41—/9- ZoJ/0 Inspected By: ?yC�[1 7 pi4/Il <br /> Facili dress: 6525 /�/. THDct<7a�� <br /> tyAdEPA ID# <br /> I certify under penalty of law that: <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--IZ—Statement <br /> J. <br /> 3'. I am authorized to submit this certification on behalf of the Respondent. 1.4 <br /> 4. 1 am aware that there ere significant <br /> penalties for submitting false information, including the y <br /> possibility of a fine and/or imprisonme t for known violations. (HSC 25191) <br /> Name: <br /> DVS: C <br /> ���� Tjt(e: ����,L o� SW <br /> Sign ure:.. Date: <br /> dayKOM <br /> b <br />