Laserfiche WebLink
SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL IfP-ALTH DEPARTMENT <br /> 304 East Weber Avenue,P Floor,Stockton,CA 95202-2708 <br /> Telephone.(209)468-3420 Fax.(209)468-3433 Web;wwrwr.sJ gov.ore/e <br /> ghd <br /> _ <br /> RETURN TO COMPLIAN E CERTIFICATION <br /> Any�.MINOR violations noted in the "Notice to CorhpIy"ill the attached inspection report must be <br /> corrected within 30 days of receipt of this inspection:, Ilii-certification form must be submitted to the <br /> Environmental Health Department(EHD) address at ih6 top of this form within 35 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 usink this certification and returned to EHD witl inn 60 days <br /> unless otherwise specified in the IR: <br /> For this certification t0 be complko th' I perator of the site must include: <br /> • A statement documenting what corrective acti6ii9 were taken or will be taken for each violation <br /> • Copies of,sample results/manifests/traitliii:iec6ld's/other a roprjqt&gapenvork,and/or photos <br /> verifying corrections ONE ,q <br /> Ro <br /> • Operator's certification' <br /> 5756 pacific Av�S�#I/ri <br /> ... (209) 477-1321 <br /> inspection Date: Inspected By: Ze , <br /> Facility Address: "��'� EPA ID#: 'L 6 q 0 <br /> I certify under penalty of law that: <br /> 1. 1 have corrected the violatil6n5 specified in' the Inspection Report om the above-mentioned <br /> inspection date. <br /> 2. 1 have personally examined the following documentation submitted as proof of compl:iancc FOR <br /> EACH'VIOLATION and I believe the information to be tnie, accurate, and complete: <br /> Photos PajJ6"Work Statement <br /> 3. I ain authorized to submit this certification on bell&of the Respondent. <br /> 4. lam aware that there are significant penalties for s0mitting false information, including the <br /> possibility of a fine and/or imprisonment for known violations. (HSC 25191) <br /> Name: p <br /> Signature: Date: <br /> EHD 22-02-005 Rev 12-04 <br />