Laserfiche WebLink
SAN JdAWA tMI NTY <br /> N <br /> a <br /> VIRONMENTAL114RAL114 DEPARTMENT <br /> 304 IiWeber Awni}c, 11>sor,Stockton,CA 95202-2708 <br /> Tel (2 )468-3420 Pax:(204)468-3433 Web:www.sjggv,gr2/eW <br /> RETVRN COMPLIANCE CERTIFICATION <br /> Any MINOR violations Noted in "Notice to Comply"in the attached inspection report must be <br /> corrected within 30 days of receip of this inspection. This certification form must be submitted to the <br /> Environmental Health Departmen EHD) address at the top of this form within 35 days of receipt of the <br /> inspection report. <br /> All corrections to other violations oted in the attached Inspection Report(IR) or Continuation Form, or <br /> disputes to any violations; are to b submitted using this certification and returned to EHD within 60 days <br /> unless otherwise specified in the 11 <br /> For this certification to be complete the operator of the site must include: <br /> • A statement documenting vbat corrective actions were taken or will be taken for each violation <br /> • Copies of sample results/ ifests/training records/other appropriate paperwork, and/or photos <br /> verifying corrections <br /> • Operator's certification �h <br /> Inspection Date: LdoK/� Inspected By: Yi <br /> Facility Address: �#A ID#: l -TIL&CO � <br /> I certify under penalty of law I tat: <br /> 1. I have corrected the violati ns specified in the Inspection Report from the above-mentioned <br /> inspection date. <br /> 2. I have personally examine 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. I am authorized to submit is certification on behalf of the Respondent. <br /> 4. 1 am aware that there are s gnificant penalties for submitting false information, including the <br /> possibility of a fine and/orimprisonment for known violations. (HSC 25191) <br /> Name: Nb(` Title: <br /> Signature: Date: `7•��� <br /> brill 22-02-005 Rev 12-04 <br />