Laserfiche WebLink
002454 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 600 EW Mein Street, Stockton,CA 952023029 <br /> Tetep lone:(269)4fle3420 Fax.(209)488-3433 Web:w m.eIg0v.orWehd <br /> RETURN TO COMPLIANCE CERTIFICATION <br /> Any MINOR violations noted In the"Notice to Comply"In the attached Inspection Report must be <br /> norreatjd within 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 30 days of receipt of the <br /> Inspection Report. <br /> Ail corrections to other violationnoted 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 30 days <br /> unless otherwise specified in the Inspectlon Report. <br /> Note: All EHD staff time associated with falling to comply by the above noted dates will be <br /> billed at the currant hourly rate. f <br /> For this certification to be Complete the operator of the site must Include: <br /> • A statement documeWng what corrective actions were taken or will be taken for each violation <br /> • Copies of sample resultWmanlfestsltralning records/other appropriate paperwork, anwor photos <br /> verifying corrections <br /> • Operator's certification <br /> Inspection Date: { Inspe By: ai'�t1 l <br /> 9y <br /> Facility Address: �5X1a'4WV1jWAA'0AID#: <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. 1 have personally examined the following documentation submitted as proof of compliance FOR <br /> EACH VIOLATION and I believe thwirdormation to be true, acc te, and complete: <br /> Photos Paperwork Statement <br /> 3. 1 am authorized to submit this certification on behalf of the Respondent. <br /> 4 I am aware that there are significant peva 'es far submitting false Information. Including the <br /> possibility of a Fine and/or I eonme VT known violations (HSC 25191) <br /> Name Titin [_�,✓ �'✓' 7 <br /> Signature Date, <br /> eno 22.02-005 ear 05MI <br />