Laserfiche WebLink
�_QSAN JOAQUIN COUNTY �/VA <br />ENVIRONMENTAL HEALTH DEPARTMENT V4 y <br />600 East Main Street, Stockton, CA 95202-3029 ' 5 2412 <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sj^ q*ehd <br />P N461v, <br />RETURN TO COMPLIANCE CERTIFICA WFRVI ESLTj� <br />Any MINOR violations noted in the "Notice to Comply" in the attached Inspection Report must <br />be corrected within 30 days of receipt of this inspection. This certification form must be <br />submitted to the Environmental Health Department (EHD) address at the top of this form within <br />30 days of receipt of the Inspection Report. HSC 25404.1.2(c)(1) <br />All corrections to other violations noted in the attached Inspection Report (IR) or Continuation <br />Form, or disputes to any violations, are to be submitted using this certification and returned to <br />EHD within 30 days unless otherwise specified in the Inspection Report. HSC 25185(c)(3) <br />Note: All EHD staff time associated with failing to comply by the above noted <br />dates will be billed at the current hourly rate. <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 <br />violation <br />• Copies of sample results/manifests/training records/other appropriate paperwork, and/or <br />photos verifying corrections <br />• Operator's certification <br />Inspection Date: April 27, 2012 Inspected By: Garrett Backus <br />Facility Address: 10858 Trinity Parkway EPA ID#: CAR000201806 <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 <br />FOR EACH VIOLATION and I believe the information to be true, accurate, and complete: <br />✓ Paperwork <br />✓ Statement <br />3. 1 am authorized to submit this certification on behalf of the Respondent. <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: Pauline C an <br />�Calalan Signature: a <br />Title: UST Compliance Coordinator <br />Date: May 23, 2012 <br />