Laserfiche WebLink
~ RECEIVED <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT MAY 3 0 2014 <br /> 868 East Hazelton Avenue, Stockton, California 95205-6232 <br /> Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.slgov.org 4hh ONMENTAL HEALTH <br /> PERMITISFiRVICES <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 days of receipt of this inspection. This certification form must be submitted to the <br /> Environmental Health De artment (EHD) address at the top of this form within 30 days of receipt of the <br /> Inspection Report. HSC 5404.1.2(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 thne associated with failingto comply by the above noted dates will be <br /> billed at the current hourly rate. � `��r <br /> For this certificcation 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 sampleresults/manifests/training records/other appropriate paperwork, and/or photos <br /> verifying correction <br /> • Operator's certification <br /> Inspection Date: O a "zf 1 Inspected By: <br /> Facility Address: 7 I ',J ���' '� S EPA ID#: 2-T <br /> S T c I le 10,EY-2 <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 lo submit this certification on behalf of the Respondent. <br /> 4. 1 am aware that 1here are significant penalties for submitting false information, including the <br /> possibility of a fine and/or imprisonment for known violations. (HSC 25191) <br /> Name: Ap-t V{ t f ft-C I-L_ Title: 0 -J"E (L <br /> Signature: k Date: Od $6 <br /> EHD 22-02-005 Rev 04/19/12 <br />