Laserfiche WebLink
SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />600 East Main Street, Stockton <br />Telephone: (209) 468-3420 Fax. CA 95202-3029 <br />(209) 468-3433 <br />C� <br />Web: ww,,y,s' ov.or lehd r to <br />� � mAUG 22 201, <br />RETURN TO COMPLIANCE CER Fr��oNM <br />TIFICATION PERMIrise vie6 ' <br />Any Mly to Comply" <br />violations noted in the "Notice in the attached Inspection Report must be <br />corrected within 30 da s of receipt of this inspection. This certific <br />Enviro <br />nmental Health Department (EHD) address at the to atron form must be submitted to t <br />p o f this form within 30 days of receipt of e <br />p the <br />Inspection Report. <br />All corrections to other violations noted in the attached Inspection <br />disputes to any violations, are to be submitted using this certification and returned to EHD <br />unless otherwise specified in the Inspection Report. Report (IR) or Continuation Form, or <br />within�a,s,s <br />Note: All END staff time associated with failin to c <br />billed at the current hourly rate. g omply by the above noted dates will be <br />For this certification to be complete the Operator <br />ust include: <br />• A statement documenting what corrective actions were taken or will be betakenthsite rfor each violation <br />on• Copies of sample results/manifests/training records/other appropriate atePaperwork, and/or photosverifying corrections <br />Operator's certification <br />Inspection Date: I_ 18 -Z® I d <br />Inspected By: <br />Facility Address: Z441S �� � � <br />°�'� EPA ID#; y- � �� Z. 2.-91 <br />I certify under penalty of law that: <br />I. I 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. (H 25 91 <br />Name: `ugts��iar 1 _- <br />Title; <br />Signature: -- <br />EHD 22-02-005 Rev 10109 <br />K_ <br />