Laserfiche WebLink
SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 600 East Main Street,Stockton,CA 95202-3029 <br /> Tele hone:(209)468-3420 Fax:(209)468-3433 Web: www.sjgov.ore/ehd <br /> RETL RN TO COMPLIANCE CERTIFICATION <br /> Any MINOR violations ned in the"Notice to Comply" in the attached Inspection Report must be <br /> corrected within 30 days o receipt of this inspection. This certification form must be submitted to the <br /> Environmental Health Dep rtment(EHD) address at the top of this form within 35 days of receipt of the <br /> Inspection Report. <br /> All corrections to other vio ations noted in the attached Inspection Report (IR) or Continuation Fonn, or <br /> disputes to any violations, re to be submitted using this certification and returned to EHD within 30 days <br /> unless otherwise specified n the Inspection Report. <br /> Note: All EHD staff time associated with failing to comply by the above noted dates will be billed at <br /> the current hourly rate ($ 8). <br /> For this certificati n to be complete the operator of the site must include: <br /> • A statement docum nting what corrective actions were taken or will be taken for each violation <br /> • Copies of sample r sults/manifests/training records/other appropriate paperwork, and/or photos <br /> verifying correctiot s <br /> • Operator's certifica ion <br /> Inspection Date: Inspected By: Orlips,` i ;,tC' <br /> r-J <br /> Facility Address: a '�'' EPA ID#:t-'�"p 1,... �_ ., n .m..:. <br /> 4 <br /> I certify under penalty f law that: <br /> 1. I have corrected the violations specified in the Inspection Report from the above-mentioned <br /> inspection date. <br /> 2. I have personally ex mined the following documentation submitted as proof of compliance FOR <br /> EACH VIOLATIOP I and I believe the information to be true, accurate, and complete: <br /> -,I- <br /> V"' <br /> y Photos V'A^ Paperwork ✓r Statement <br /> 3. 1 am authorized to s bmit this certification on behalf of the Respondent. <br /> 4. I am aware that ther are significant penalties for submitting false information, including the <br /> possibility of a fine nd/or imprisonment for known violations. (HSC 2519 1) <br /> Name: > S R� Title: /�XIV AGES_ <br /> Signature: Date: <br /> EHD 22-02-005 Rev 11/07 <br />