Laserfiche WebLink
SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 600 East Main Street,Stockton,CA 95202-3029 <br /> Telephone.(249)468-3420 Fax. (209)4653433 TVeh:vrww.sieov.orcretzd <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 /> Environmental Health Department (EHD) address at the 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 Foran, 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 billed at <br /> the current hourly rate ($98). <br /> For this Certification t0 be Complete the operator of the site must include: <br /> e A statement documenting what corrective actions were taken or will be taken for each violation <br /> e Copies of sanYple results/inanifests/training records/other appropriate paperwork, and/or photos <br /> verifying corrections <br /> o Operator's certification <br /> Inspection Date:_ 1, ( t Inspected <br /> Facility Address: q2 I Y&V { A-Ind. EPA ID#: 00-0 303 t_ 4 <br /> S�acl��-a>�►�erg �S�Zl� <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 infonrration to be true, accurate, and complete: <br /> Photos_X—Paperwork Statement <br /> 3. 1 atm 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 2519 1) <br /> Name: <br /> Date: <br /> Signature: Z .= <br />