Laserfiche WebLink
I <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 600 East Main Street, Stockton, CA 95202-3029 <br /> Telephone:(209) 468-3420 Fax:(209)468-3433 Web:www:sigov.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 tib the <br /> Environmental Health Department(EHD) address at the top of this form within 30 days of receipt of the <br /> Inspection Report. - <br /> All corrections to other violations noted in the attached inspection Report (I R)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 /> I <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 t0 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 j <br /> Inspection Date: Q� Inspected By: GA,2aerr Rxi-e-lzvs <br /> 1 n 2nb1-rD Srt��� <br /> Facility Address: G4V e, hvt, � EPA ID#: M 0007, }3068 <br /> I 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 /> Photos I 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 <br /> of a fine and/or imprisonment for known violations. (HSC 25191) <br /> Name: <br /> Signature: Date: <br /> j <br /> EHD 1202-005 Rev OBlOB <br />