Laserfiche WebLink
SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 600 East Main Street, Stockton, CA 95202-3029 <br /> Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.sigov.org/ehd <br /> RET6RN 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 specifie in the Inspection Report. <br /> (Vote: All EHD staff ti a associated with failing to comply by the above noted dates will be <br /> billed at the cu rent hourly rate. <br /> For this certific tion 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 re ults/manifests/training records/other appropriate paperwork, and/or photos <br /> verifying corrections <br /> Operator's certificati n <br /> Inspection Date: y Inspected By: - C -/ � crc <br /> Facility Address: (o S Vit_ Z� C�tirEPA ID#: @A L U <br /> c'a 'nto CA 52� <br /> I certify under penalt of law that: <br /> 1. 1 have corrected he 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 VIOLATI N and I believe the information to be true, accurate, and complete. <br /> Photos w ` Paperwork Statement <br /> 3. 1 am authorized t submit this certification on behalf of the Respondent. <br /> 4. 1 am aware that there are significant penalties for submitting false information, including the <br /> possibility of a fi and/or imprisonment for known violations. (HSC 25191) <br /> Name: ct� Title: <br /> Signature: ti Date: <br /> EHD 22-02-005 Rev 10M <br />