Laserfiche WebLink
An <br /> RECEIVE® <br /> �S <br /> SAM JOAQUIN COUNTY DEPARTMENT NOV 07 2013 <br /> NwRONMTxrn�HEALTH <br /> \N 600 East Main Street„Stoddm,CA 95202-3029 <br /> Telephone:(209)468-3420 ter:(209)468-3433 wen.�.siqwv-«wend ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> RETURN TO COMPLIANCE CERTIFICATION <br /> Any MINOR violations noted in the-Notice to Cornply'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(cx3) <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/manaests6training records/other appropriate paperwork,and/or photos <br /> verifying corrections <br /> • Operator's certification <br /> Inspection Date: /fl 7/�3 Inspected gy:Stacy Rivera <br /> r r c� / _ <br /> Facility Address: y676� FPA ID#: C AL 0 0 0 3 f 1 Z Co to <br /> i <br /> 1 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 auftwrized 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 n l ( ve e L Title: PLO-^rr'y/g?Aj'4 <br /> Signature: Of�' Date: t I G / <br /> EHD 71-02-005 Rev OHMS <br />