Laserfiche WebLink
MAO. 2010 11 : 36AM No. 9248 P. 1/1 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 800 East Main Street, Stockton, CA 95202-3029 d <br /> Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.slaov.orgtehd <br /> JUL 3 0 two <br /> 3AN COUNTY <br /> RETURN TO COMPLIANCE CERTIFICATION :;AL <br /> Ham!TFt C'_; •,; TF:{CNT <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 <br /> Inspection Report_ <br /> All corrections 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 days <br /> unless otherwise specified in the Inspection Report. <br /> Note: All EHD staff time associated with failing to comply by the above noted dates will be <br /> billed at the current hourly rate of$105 (beginning 8/1/09 the hourly rate will be $115). <br /> For this certification to 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 results/manifests/training records/other appropriate paperwork, and/or photos <br /> verifying corrections <br /> • Operator's certification <br /> Inspection Date: �2I1�1 � D Inspected By: (V41,t,11� N <br /> 11 <br /> Facility Address: -lqa� S h 6�w Co EPA ID#: 0/4k/ovo [9 Z50 <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 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: Title: C)Q e v.t Yl'1 ask.g er <br /> Signature: Date: (> — <br /> EHD 22-02-005 Rev 06109 <br />