COMPLIANCE INFO_PRE 2019 - Laserfiche WebLink

Home Browse Search

41, SAN JOA91UIN COUNTY ENVIRONMENTAL. HEALTH DEPARTMENT 304 East Weber Avenue, 3rd Floor, Stockton, CA 95202-2708 Telephone: (209) 468-3420 Fax: (209) 4683433 Web:www &i v.o ehd RETURN TO COMPLIANCE CERTIFICATION Any M_�R violations noted in the "Notice to Comply" in the attached inspection report must be corrected within 30 da s of receipt of this inspection. This certification form must be submitted to the Environmental Health Deparftnent (EHD) address at the top of this forrn within 35 days of receipt of the inspection report. 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 EHD within 60 days unless otherwise specified in the IR - For this certification t0 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 results/manifests/training records/other appropriate paperwork, and/or photos verifying corrections ^' • Operator's certification Inspection Date: 5_ 6 --DS _ _ Inspected By: r= N C, S I H Facility Address: d% 2Antiy (..): gTa<xa; EPA ID#: CA_ gSZob I, certify under penalty of law that: 1. I have corrected the violations specified in the Inspection Report from the above-mentioned in.spe6tion date_ 2. T have personally examined the following documentation. submitted as proof, of compliance FOR EACH VIOLATION and Z believe the information to be. true, accurate, and complete: Photos Paperwork v, Statement 3. I am authorized to submit this certification on behalf of the Respondent. 4. I am aware that there are significant penalties for submitting false information, including the possibility of a fine and/or imprisonment for known inlations. (HSC 25191) Name:_��4K� I X? &cam Title: r Afec**V, C, Sinari�re: ��,,G� Date: C -ot 3 DS ET -TD 22-02-005 Rev 12-04