Laserfiche WebLink
• SAN JOAQUIN COUNTY *AEGEIVED <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 600 East Main Street, Stockton, CA 95202-3029 <br /> Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.s'gov.org/e 1 2 2013 <br /> ANJOAQUINCOUNTY <br /> —®W-- _ ENVIRONMENTAL <br /> RETURN TO COMPLIANCE CERTIFICATIHEALTH <br /> N HOEPARTMENT <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. HSC 25404.1.2(c)(1) <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. HSC 25185(c)(3) <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. <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 results/manifests/training records/other appropriate paperwork, and/or photos <br /> verifying corrections <br /> • Operator's certification / <br /> Inspection Date: (0/o/ �-3 Inspected By:StaCy Rivera <br /> Facility Address: S- 1�i�700t-t LUkaf,( EPA ID#: (&VOOZ&�*Z,3 <br /> I certify under penalty of law that: <br /> 1. I 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. lam aware that there Tnificant penalties for submitting false information, including the <br /> possibili e d o onment for known violations. (HSC 25191) <br /> Name: — vr� "l ie: axtT4,r <br /> Signature: Date: <br /> EHD 22-02,005 Rev 09111 <br />