Laserfiche WebLink
r <br />GSAN JOAQUIN COUNTY y <br />ENVIRONMENTAL HEALTH DEPARTMENT I'J.cA?,i <br />600 East Main Street, Stockton, CA 95202-3029 - <br />Telephone: (209) 468-3420 Fax. (209) 468-3433 Web: www• ov.or end JUL O $ dojo <br />:irAL <br />RETURN TO COMPLIANCE CERTIFICATION "''` `rMENr <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. <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. <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 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. <br />/1-22 al'o <br />__ZZ <br />Facility Address: 3 A). G .4 <br />I certify under penalty of law that: <br />Inspected By:�/�/Z��� <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 following documentation submitted as proof of compliance FOR <br />EACH VIOLATION and I believe the information to be true, accurate, and complete: <br />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 25191) <br />Name: <br />Signature: <br />EHE) 22-02�0oS Rev 10109 <br />Title: i <br />Date: <br />L0!'S0 3eVd ONI SIO 3d�JOH1 b.JIF TS8T-898-60Z-T 60:bT 3TOZJ80/L0 <br />