Laserfiche WebLink
002454 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 600 East Main Street Stockton CA 95202-302.9 <br /> ID <br /> :360e:(209)468-3420 Fax:(209)468-3433 Web:www.segov.org/ehd <br /> ?Q10 <br /> RETURN TO COMPLIANCE CERTIFICATION <br /> Any MINOR viol9gons no, d in the "Notice to Comply" in the attached Inspection Report must be i <br /> corrected within 30 daysreceipt of this inspection. This certification form must be submitted to the <br /> Environmental Health Department (EHD) address at the top of this form within 30 days of receipt of the i <br /> Inspection Report. <br /> I <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. <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 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 /> • <br /> Operator s certification <br /> Inspection Date: />� /� Inspected By: <br /> Facility Address: ,2J /J�(rJ �S�CrrIPA ID#: <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 L�/ Statement <br /> 3. 1 am authorized to submit this certification on behalf of the Respondent. <br /> I <br /> 4 1 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 /> f' <br /> Name:- 4 �'��- � �l Title: <br /> Signature: �� Date- l 6 v <br /> EHD 22-02.005 Rev 08/08 <br />