Laserfiche WebLink
Oot 17 12 08: 00a p. 4 <br /> • i <br /> SAN JOAQUIN COUNTY - RECEIV"' D <br /> ENVIRONMENTAL HEALTH DEPARTMENT600 East Main Street,Stockton, CA 95202-3029 <br /> Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.sigov.orq/ehd <br /> OCT 1 7 2012 <br /> SANJOAQUIN COUNTY <br /> RETURN TO COMPLIANCE CERTIFICATION H�iT14DE ARTi ENT <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 30 days of receipt of the <br /> 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 <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. 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 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 /> Inspection Date: 9A41 + Inspected By: -11644 -4!tA ��`Ys <br /> �V'0 �t rtff ��•oo <br /> Facility Address: ZX�i L�� 9f3�+/ EPA ID#: G�,4G c>tYa 33�?� fb <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 t/Isaperwork ti-�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 <br /> possibility of a fine and/or imprisonment for known violations. (HSC 25191) <br /> Name: <br /> ,�o B WaoO Title: R1 -Q- iC <br /> Signature: Date: ,' <br /> EHO 22-02-005 Rev 9111 <br />