Laserfiche WebLink
SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT o� <br /> 600 East Main Street, Stockton, CA 95202-3029 <br /> Teleph no:(209) 468-3420 Fax: (209)468-3433 Web:www.siQov.org/ehd <br /> RET RN 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 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 tie associated with failing to comply by the above noted dates will be <br /> billed at the cur ent hourly rate. <br /> For this certifica ion to be complete the operator of the site must include: <br /> • A statement docume ting what corrective actions were taken or will be taken for each violation <br /> • Copies of sample res Its/manifests/training records/other appropriate paperwork, and/or photos <br /> verifying corrections <br /> • Operator's certificatio <br /> InInspected Bspection Date: � A Y• ' <br /> Facility Address: U; <br /> VPA ID#: �}��aQ � �/:5 <br /> I certify under penalty f 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 /> s <br /> _Photos _Paperwork Statement <br /> 3. 1 am authorized to submit this certification on behalf of the Respondent. <br /> i <br /> 4. 1 am aware that there are significant penalties for submitting false information, including the <br /> possi ility of a fine and/or imprisonment for known violations. (HSC 25191) <br /> 25191) <br /> Name: Title: CIO <br /> Signature: Date: <br /> ITO/IIOf� 'XI 'IMI1 IIH13 NIT �9I 60Z XF3 INT Hill 600NO/N <br />