Laserfiche WebLink
i • <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT �� <br /> '/ <br /> 600 E.Main St.,Stockton,CA 95202-3029 ��I /�® <br /> Telephone:(209)468-3420 Fax:(209)468-3433 Web:www si eov ore%hd <br /> EP.1 <br /> RETURN TO COMPLIANCE CERTIFICATI I ERM17 SERVICES <br /> Any MINOR violations noted in the"Notice to Comply"in the attached Inspection Report must be <br /> corrected within 10 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 35 days of receipt of the <br /> Inspection Report <br /> All corrections to other violations noted in the attached Inspection Report 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 billed at <br /> the current hourly rate($125). <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 /> F <br /> n Date: 8-2.3 —ZO I Inspected By: rH(/Y T 1Zgr1 <br /> Address: ZoZ o $PA ID#: CA K 0 0 0 16 q13 7 <br /> fy 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. I 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 V Paperwork VaStatement <br /> 3. I am authorized to submit this certification on behalf of the Respondent. <br /> 4. I 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:MAKK 6A213vs,4 Title:r'I^1,re*. ,wce Mq�gFc� <br /> Signature: Date: 9— 8- -401 1 <br /> EHD 22-02-005 Rev 08/10 <br />