Laserfiche WebLink
JOA <br /> UIN <br /> SAE TAL HEA t.ODIVTyENv / 7� <br /> 600 E. MENTAL HEALTH CA 95ARTMII9T •/�/( CE <br /> 600 8-Main St.,Stockton,CA 9 Web: <br /> (v= /V47D <br /> Telephone:(209)468-3420 Fac:(209)468-3433 Web:www.siRov.orglehd <br /> RAY I <br /> 57008 <br /> RETURN TO COMPLIANCE CERTIFICATIOl N goN,Nco�N <br /> FacryoE nMcNOu ry <br /> Any MINOR violations noted in the"Notice to Comply"in the attached Inspection Report must tENr <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 35 days of receipt of the <br /> Inspection Report. <br /> All corrections to other violations noted in the attached Inspection Report 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 /> Note: All EHD staff time associated with failing to comply by the above noted dates will be billed at <br /> the current hourly rate($98). <br /> For this certification to 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 <br /> Inspection Date: -7 /o?00 250' Inspected By: h0AV V0 V) (,t e.l P E�fS <br /> Facility Address: VI /7R EPA ID#:G,#7-eW 0 -e7L <br /> 5'To Vow 75 7_0(v <br /> I certify under penalty of law that: <br /> I. I have corrected the violations specified in the Inspection Report from the above-mentioned <br /> inspection date. <br /> 2. I 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 V Paperwork Statement <br /> 3. I am authorized to submit this certification on behalf of the Respondent. <br /> 4. I 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 25191) v1 <br /> Name: �� � t I OM A- :> Title: TEMA I OA-1 <br /> Signature: ate_ Date: / 3 <br /> EHD 22-02-005 Rev 7 <br />