Laserfiche WebLink
Any MINOR violations i <br />corrected within 30 days <br />Environmental Health D <br />Inspection Report. <br />All corrections to other N <br />disputes to any violation <br />unless otherwise specific <br />Note: All EHD staff tin <br />the current hourly rate <br />For this certifica <br />• A statement docs <br />• Copies of sample <br />verifying correct <br />• Operator's certif <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />600 East Main Street, Stockton, CA 95202-3029 <br />(209) 468-3420 Fax: (209) 468-3433 Web: www.sigov.org/ehd <br />TO COMPLIANCE CERTIFICATION <br />-d in the "Notice to Comply" in the attached Inspection Report must be <br />receipt of this inspection. This certification form must be submitted to the <br />rtment (EHD) address at the top of this form within 35 days of receipt of the <br />4ations noted in the attached Inspection Report (IR) or Continuation Form, or <br />are to be submitted using this certification and returned to EHD within 30 days <br />in the Inspection Report. <br />associated with failing to comply by the above noted dates will be billed at <br />on to be complete the operator of the site must include: <br />ienting what corrective actions were taken or will be taken for each violation <br />esults/manifests/training records/other appropriate paperwork, and/or photos <br />Inspection Date: • <br />Facility Address: 2�6 Jai. Cjz <br />I certify under penaltj of law that: <br />Inspected By: ArIS; Cq <br />f EPA ID#: C-9 n—m'6-' "2J 56' 5S <br />CA 157-2-;f- <br />1. I have corrected t e violations specified in the Inspection Report from the above-mentioned <br />inspection date. <br />2. I have personally amined the following documentation submitted as proof of compliance FOR <br />EACH VIOLATION and I believe the info tion to be true, accurate - --- <br />and complete: <br />✓ <br />Photos Paperwork Statement <br />3. lam authorized <br />4. lam aware that <br />possibility of a <br />Name:_, <br />Signature&l <br />submit this certification on behalf of the Respondent. <br />e are significant penalties for submitting false information, including the <br />and/or imprisonment for known violations. (HSC 2519 1) <br />Title: A53VC A c? <br />Date:—' <br />EHD 22-02-0O5 Rev 08/1 <br />0-S4Y.ZL�{ (�) aAYk�- <br />� � 1 <br />�b <br />