Laserfiche WebLink
SAN JOAQUIN COUNTY 111 <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />600 E. Main St., Stockton, CA 95202-3029 <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sigov.org/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 />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 Form, or <br />disputes to any violations, are to be submitted using this certification and returned to EHD within 60 days <br />unless otherwise specified in the IR. <br />For this certification to be complete the operator of the site trust 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 />verifying corrections <br />• Operator's certification <br />Inspection Date: �o/w o7 <br />013a Hari( <br />Facility Address: Sk:clGkn CA <br />I certify under penalty of law that: <br />Inspected By: &u ozo Elsie <br />EPA ID#:CAA onca W4 C?q`f <br />1. I have corrected the violations specified in the Inspection Report from the above-mentioned <br />inspection date. <br />2. I 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 n Paperwork 'X Statement <br />3. I am authorized to submit this certification on behalf of the Respondent. <br />4. I 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 />Ci'M-AJ`a,LOti.JY W�r,%cJ <br />Name:, 4 F 6 Title.{_ .cam �c <br />Date:-7/!o/i3 <br />EHD 22-02-005 Rev 05-07 <br />