Laserfiche WebLink
May 04 2011 4: 05PM Pi OS 'VE 209-2 '-9991 p. 1 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT rnAY 0 2011 <br /> 600 East N4niq 5trzat,Stockton,CA 95202-3029 <br /> Tl►phone:(209)468-3420 Far:(209)468-3433 Web. w s' r <br /> RETURN TO COMPLIANCE CERTIFICATION <br /> Any MINOR violations noted in the"Notice to Comply" in the attached Inspection Report must be <br /> corrected w' 3 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 co ons 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 0 da <br /> ys <br /> unless otherwise specified in the Inspection Report. <br /> Note: All EHD ,teff time associated with failing to comply by the above noted dates will be billed at <br /> the current hou�y rate 4$122). <br /> For this ce if1Ca 'Ori t0 be Complete the operator of the site must include: <br /> • A statetn t 'on <br /> what corrective actions were taken or will <br /> be taken for each violation <br /> • Copies of sample results/manifeststtrainirig records/other appropriate paperwork, and/or photos <br /> verifying orrecti�'ns <br /> • Operator' certification <br /> Inspection Date:A 11 Inspected By:� <br /> Facility Address: EPA ID*AAAj-Zc:f <br /> I certify under penal of law that: <br /> 1. I have cortrted. violations specified in the Inspection Report from the above-mentioned <br /> inspection date. <br /> 2. I have personally annined the following documentation submitted as proof of compliance FOR <br /> EACH VI LATI N and.1 believe the information to be true, accurate, and complete: <br /> Photos Paperwork Statement <br /> 3. 1 am authorized to ubmit this certification on behalf of the Respondent. <br /> 4. l 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; Title- n m' <br /> Si ature: WxbDate: <br /> EHD 22-02-005 Rev 08/10 <br />