Laserfiche WebLink
SLS SAN JOAQUIN COUNTY / k4 f Io�6 S <br /> L ENVIRONMENTAL HEALTH DEPARTMENT <br /> t 600 East Main Street, Stockton, CA 95202-3029 <br /> Telephone: (209)468-3420 Fax: (209)468-3433 Web:www.siQov.orq/ehd <br /> RETURN TO COMPLIANCE CERTIFICATION "qZ'0' <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. <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 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 results/manifests/training records/other appropriate paperwork, and/or photos <br /> verifying corrections <br /> • Operator's certification <br /> ofN4 l 6A s <br /> Inspection Date: 4 V c I 20�I Inspected By:�} /�—F71- CRUS <br /> Facility Address: ���G ��'� G14� & EPA ID#: 0000 (6gd g' <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 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: P,6,'re2 Title: v4MAII <br /> SignatLre: Date: <br /> r <br /> EHD 22-02-005 Rev 10109 RETURN TO COMPLIANCE <br /> I •d dsa =e0 60 oz 090 <br />