Laserfiche WebLink
SAN JOAQUIN COUNTY 1 c <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 600 E.Main St.,Stockton,CA 95202-3029 <br /> Tekphone:(209)468-3420 Fox.(209)468-3433 Web.www.sieov.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 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. <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($1217. <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/manifests/training records/other appropriate paperwork,and/or photos <br /> verifying corrections <br /> • Operator's certification <br /> Inspection Date: �/2 �)� Inspected By: <br /> Facility Address: lAwy 5S SI.c1d-.EPAID#: <br /> I certify under penalty of law that: <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 Paperwork_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 /> Name: /14. 1 S-, Title:_ C- e:,O(°r& ltcGkcjq­ <br /> Signator . Date: 7/z f I <br /> EHD 22-02-005 Rev 08/10 ((�� <br /> Ivo 110 111 WG 5 (>' &> r sH <br /> / ! li/t II In 4V{ 1`^+� GKN�tcl ��J4 � cJJ <br /> �L( we well iµs..rc -{t-4t -I-c.� Oo. d <br /> oGuus+ +s rid <br />