Laserfiche WebLink
SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1868 East Hazelton Avenue, Stockton,California 95205-6232 <br /> Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.s19oy.or4`.ehd <br /> RETURN TO COMPLIANCE CERTIFICATION <br /> AnylM NOR violations noted in the "Notice to Comply" in the aftached 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(END)address at the top of this form within 30 days of r�.eipt of the <br /> Inspection Report. HSC 25404.1.2(c)(1) <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 30 da_�Ls <br /> unless otherwise specified in the inspection Report_ HSC 25185(c)(3) <br /> Note: All EHD staff time associated with failing to comply by the above noted dates will be <br /> billed at the current hourly rate. <br /> For this certification to be complete the operator of the site must include: <br /> . A staternent 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 Dafie:_ — ^ r �' Inspected By:�� l n6�s <br /> Facility Address:( &; Lc1• « S.1% ERA ID#: <br /> 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 l believe the information to be true, accurate, and complete: <br /> Photos a Paperwork J� Statement <br /> 3. 1 am authorized to submit this certification on behalf of the Respondent. <br /> 4. l am aware that there are significant penalties for submitting false information, including the <br /> possibility of a fine andfor imprisonment for known violations. (HSC 25191) <br /> Name: Title: <br /> Signature: Date: <br /> EHD 2z-o1.005 Rev 04116112 <br />