Laserfiche WebLink
SAN JOAQUIN Environmental Health Department <br /> ----COUNTY— <br /> • Grta:nrss crr�.s „cr, . <br /> RETURN TO COMPLIANCE CERTIFICATION <br /> Any MINOR violations noted in the`Notice to Comply'in the attached Inspection Report must be corrected within 30 days of <br /> receipt of this inspection. This certification form must be submitted to the Environmental Health Department(EHD)address <br /> at the top of this form within 30 days of receipt of the 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 disputes to any <br /> violations,are to be submitted using this certification and returned to EHD within 30 days unless otherwise specified in the <br /> 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 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 sample resultslmanifestsllraining recordslother appropriate paperwork,and/or photos verifying <br /> corrections <br /> Operator's certification <br /> Inspection Date: November 07, 2017 Inspected By: CESAR RUVALCABA <br /> Facility Address: 15600 S HARLAN RD, LATHROP i ID: 10180541 <br /> I certify under penally of law that: <br /> 1. 1 have corrected the violations specified in the Inspection Report from the above-mentioned inspection date. <br /> 2. 1 have personally examined the following documentation submitted as proof of compliance FOR EACH VIOLATION <br /> 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. 1 am aware that there are significant penalties for submitting false information,including the possibility of a fine <br /> and/or imprisonment for known viol ions. (HSC 25191) <br /> Name: / ►,( SI. <br /> Title: <br /> Signature: f Date: <br /> cAe-W <br /> RECEIVED <br /> E® <br /> DEC 01 2017 <br /> ENVIRONMENTAL HEALTH ?rA0,Oool7q <br /> DEPARTMENT <br /> 1868 E. Hazelton Avenue I Stockton,Califomia 95205 1 T 209 468-3420 1 F 209464-0138 1 www.s(c:olxl.cnm <br />