Laserfiche WebLink
SAN JOAQUIN COUNTY ������ <br /> NVIRONMENTAL HEALTH DEPARTMENT* <br /> 600 E. Main St., Stockton, CA 95202-3029 <br /> Telephone:(209)468-3420 Fax.(209)468-3433 Web:www.s4gov.org/ehd AIL L 3 2013 <br /> ENVIR0141WWO ALTH <br /> RETURN TO COMPLIANCE CERTIFICATION PERMIT/SERVICES <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 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 ($115). <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 /> l I" <br /> Inspection Date: �l l 1 I � Inspected By: AL jylwx22L� <br /> Facility Address: � J S I ip� �°�� • _ �1 Mcg EPA ID#: `1y1✓ 03 a <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✓ / <br /> I believe the information to be true, accurate, and complete: <br /> /\ Photos / Paperwork K Statement <br /> 3. 1 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: � � C,/ ✓n� " Title: � �'� <br /> Signature: Date: , f b <br /> EHD 22-02-005 Rev 10-07 <br />