COMPLIANCE INFO_PRE 2019 - Laserfiche WebLink

Home Browse Search

SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 600 E.Main St.,Stockton,CA 95202-3029 Tele hone:(209)468-3420 Fax.(209)468-3433 Web:www.sjgov.org/ehd RET RN TO COMPLIANCE CERTIFICATION Any MINOR violations n ted in the"Notice to Comply"in the attached Inspection Report must be corrected within 30 days o receipt of this inspection. This certification form must be submitted to the Environmental Health Der artment(EHD) address at the top of this form within 35 days of receipt of the Inspection Report. All corrections to other violations noted in the attached Inspection Report or Continuation Form, or disputes to any violations, a to be submitted using this certification and returned to EHD within 30 days unless otherwise specified 'n the Inspection Report. Note: All EHD staff tim as cia edwith failing to comply by the above noted dates will be billed at the current hourly rate ( 5). Z For this certificate r1 t0 be Complete the operator of the site must include: • A statement doc enting what corrective actions were taken or will be taken for each violation • Copies of sample r sults/manifests/training records/other appropriate paperwork, and/or photos verifying correctio s • Operator's certific ion Inspection Date: Inspected By: Facility Address: ri1 Ur �fEPA ID#: 0$wD I certify under penaltyf law that: 1. I have corrected the violations specified in the Inspection Report from the above-mentioned inspection date. 2. I have personally a amined the following documentation submitted as proof of compliance FOR EACH VIOLATIO and I believe the information to be true, curate, and complete: T Photos--K--Paperwork Statement 3. lam authorized to submit this certification on behalf of the Respondent. 4. I am aware that ther are significant penalties for submitting false information, including the possibility of a fine d/or imprisonment for known violations. (HSC 25191) Name: ZAV Title: Signature: Date: 36 EHD 22-02-005 Rev 10-07