Laserfiche WebLink
05/01/2007 09: 17 2099519352 +ILLAGE i.4EST t-dARINA PAGE 02 <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />304 East Weber Avenue, 3r4 Floor, StOch011, CA 95202-2708 <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www aiQov.ar$(eh <br />RETURN TO COMPLIANCE CERTIFICATION <br />,Any MINOR violations noted in the "Notice to Comply,, in the attached inspection report must be <br />cthe <br />orrected within 30 days of receipt of this inspectio .thThi s certification <br />ithis form within <br />35 days of receiptitted oof the <br />Environmental Health Department (EHD) address op <br />inspection report. <br />All corrections to other violations noted in the attached lixspection Report (IR) or Continuation Form, or <br />disputes to any violations, are to be submitted using this certification and returned to EHD within 60da s <br />unless otherwise specified in the IR. <br />For this certification t0 be complete the operator ofo e sill te m taken for each violation <br />• A statement documenting what corrective actions were taken <br />• Copies of sample results/manifests/training records/Other appropriate pap"ork, and/or photos <br />verifying corrections <br />• Operator's certification <br />Inspection Date: 'a <br />Facility Address: <br />I certify under penalty of law that: <br />Inspected BBY440t�,'"_ <br />EPA' ID# flb� 7 <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 fallowing doournentation submitted as proof of compliance FOR <br />EACH VIOLATION and I believe the information to be true, accurate, and complete: <br />PhotosPaperwork 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 2519 1) <br />Name: <br />EHD 22-02-005 Rev 12-04 <br />Date: /� a <br />