Laserfiche WebLink
SAN JOAQUIN COUNTY <br /> ENVIRQNMj ENTAL Iii.EALTH DEPARTMENT <br /> 30416t*eI_W?*VOUOAFloo[,Stockton,CA 95202-2708 <br /> TelepNohe,(309) <br /> 468-3420�'i (209)4618-3433 Web w� 0 cr8/ehd <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 dans of receipt of this inspection. This certification form must <br /> be submitted to the <br /> Envirolurlenfal Health Department(EHD)address at the top of this form within 35 days of receipt of the <br /> inspection.report..' <br /> All-corrections to other violations noted in the attached'hrspection Report-(IR) or Continuation Form,or <br /> disputes,tdany violations,are to be submitted using this certification and returned to EHD within 60 days <br /> unless otherwise specified in the IR. <br /> For this certiflcati011 t0 be COlriplete the operator of the site most include: <br /> • A statement documenting what.coriective actions were taken or will be taken for each violation <br /> • Copies of sample results/manifests/training records/other appropriate paperwork,and/or.photos <br /> verifying corrections <br /> • Operator's certification <br /> Inspection.Date: I�' s— Inspected By: <br /> Facility Address: 3 ��a N /"/u c f t>�ru✓ EPA ID#: L_ <br /> I comfy under penalty of I'aw that: <br /> 1. I have corrected the violations specified in the Inspection Report,from the above-mentioned . <br /> inspection date <br /> 2 I li'ave'personally examined the following docuentation submitted as proof of compliance FOR <br /> EACH VIOI AT .10N and I believe the info rMmation to be tine, accurate, and,completeC <br /> Photos Paperwork- Statement,+ ' <br /> 3. I amauthorized to submit this certification on behalf of the Respondent. <br /> 4. I aiiLii 990hat there are slgmf'cant penalties.fpr sµbAlitting false information,including the <br /> pos`s'i4ility of a C1ne andlor imprisonment fprknown violations. (HSC 25191) <br /> q. <br /> Name: C f j l _Title: ( � <br /> Signature: mate: <br /> EHD 2 02 OPS Rey 12-04 <br /> ZOO Inxvj 81:CZ 6002/5Z/LO <br />