Laserfiche WebLink
ENVIRONMENTAL HEALTH DEPARTME14T <br /> 604 East Main Street, Stockton, CA 96202-3029 <br /> Telep'ton.2.(209) 468-3420 Fax: (209)468-3433 Web:www.slgov,oM ehd_ <br /> RETURN TO COMPLIANCE CERTIFICATION <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 /> Environixiental Health Department (EHD) address at the top of this form within 30 gays 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'.,4,61 <br /> ny violations, are to be submitted using this certification and returned to EHD within 30 days <br /> unless ofwise specified in the Inspection Report. <br /> Note: &OND staff time associated with failing to comply by the above noted dates will be <br /> billed at the current hourly-rate. <br /> For thI 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 /> verfj-ing corrections <br /> - O �or's certification <br /> Inspection Date: Inspected By: <br /> Facility Address: qRa_5�Hw-1 F"AThfA *)EPA ID#: <br /> I certify under penalty of law that: <br /> 1. 1 Piave 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 �aperwork 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 /> passibility of a fine and/or imprisonment for known violations. (HSC 25191) <br /> Name: S � - S 1 *' Title: V✓rl� , <br /> signature,/` ! _�.. ....s. Date: <br /> EHD 22-02-OUS Rev OW06 <br /> Zoo In Q00,3VSV0C101Mb[ OLS9OMOZ W3 Zt:CT 6009/CT/TO <br />