Laserfiche WebLink
SAN JOAQUIN C✓DUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1863 East hazefton Avenue, Stockton.California 95205-6232 <br /> Telephone:(2091 468-3420 Fax:(209)465-3433 Web.w%vw-sjaov.ora/ehd <br /> RETURN TO COMPLIANCE CERTIFICATION <br /> Any IVANOR violations noted in the 'Notice to Compry' in the attached Inspectier. Repor! must be <br /> wrrected within 30 days of recent of this inspection This certification form must De submittea to the <br /> Environmental Health Department i,EHU• address at the top of this form v:ithir; 30 da)'s of r e:;eipt Of tha. <br /> Inspection Report. HSC 25404 1.2(c)(1► <br /> AV corrections to other violations noted in the attzched inspection Report(IR) or Cor inuation Form, or <br /> disputes to any violations,are to be submitted using this certification and resumed to EHD within 30 ddvs <br /> unless otherwise specified in the Inspection Report. -ISC 25'65(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 :he operator of the site must inclWe <br /> • A statement documenting what corrective act ons were taken c;r will be!aken fcr each violatior. <br /> • Copies of sample resultslmanifesls/training records/other appropriate paperwork, and/or photos <br /> verifying corrections <br /> • Operator's certitication <br /> -- � Inspected By:Elena Manzo <br /> Mrtspection Date:_ -- �-- _-- --.. .. _ _ <br /> Facility address: ;���-- � -: 1 EPA IDxf: L nQ0 -3— 3 <br /> I J � <br /> I ? <br /> I cert!fy+ under penalty of law that: I <br /> t I have corrected the violations specified in tl'.e Inspection Report from the above-menfioned <br /> k inspection date <br /> Z. i ha we personany examined the following documentation submitted as proof of compliance FOR <br /> EACH VIOLATION and I believe the information to be true, accurate, and complete l <br /> i <br /> Photos� P3perNork_Statement <br /> I 3 1 am authorized to submit this certificabon on beha'f of the Respondent. <br /> I j <br /> 4 i r m aware that there are significant penalties for subm.1ting fa;se information, including the <br /> possibi;ify of a fine andior imprisonment for known violations (HSC25191i <br /> I � i <br /> i Name. Titre:._ -r— <br /> i r <br /> I Signature: Date: �N <br /> °h:ra"i-0c-0�5 Ray 04.'19:'. , t L <br /> L'd Z LKM909 ��e�;eur�i I1 G 2 e5 2015 <br /> AVIR'ONMENTAi <br /> 1-ICA 1'ri J'1COA OT4XC4IT <br />