Laserfiche WebLink
11 <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />500 East Main Street, Stockton, CA 95202-3029 <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 WeD:www.sjgov.orcL1ehd <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 30 days of receipt 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 days <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 t® 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 recordslother appropriate paperwork, and/or photos <br />verifying corrections <br />• Operator's certification <br />Inspection Date: S <br />Inspected y: Stacy Rivera <br />Facility AddressEPA ID#: <br />cs '%7•�, C4, 5}5)0/ <br />1 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 information to be true, accurate, and complete: <br />_X Photos Paperwork Statement <br />3. 1 am 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 255194 ) <br />Name:o �rJ Title: /Vffr' <br />Signature: r/ _ Date: <br />EHD 22-02-005 Rew 09'1' <br />