Laserfiche WebLink
San Joaquin County <br /> Environmental Health Department <br /> 1868 East Hazelton Avenue, Stockton, California 95205-6232 <br /> Telephone: (209) 468=3420 Fax: (209) .4684M33 Web: M= §jgoy.orgMhd <br /> RETURN TO COMPLIANCE CERTIFICATION <br /> Any MINOR violations noted in the "Notice to Comply" In the attached Inspection Report must be corrected within 30 days of <br /> receipt of this inspection. This certification form must be submitted to the Environmental Health Department (EHD) address <br /> at the top of this form within 30 days of receipt of the Inspection Report. HSC 25404, 1 ,2(c)(1 ) <br /> All corrections to other violations noted in the attached Inspection Report (IR) or Continuation Form, or disputes to any <br /> violations, are to be submitted using this certification and returned to END within 30 days unless otherwise specified In the <br /> Inspection Report. HSC 25185(c)(3) <br /> Note: All EHD staff time associated with failing to comply by the above noted dates will be <br /> billed at the current hourly rate. <br /> For this certification to be complete , the operator of the site must include: <br /> • A statement documenting what corrective actions were taken or will be taken for each violation <br /> • Copies of sample results/manifesta training records/other appropriate paperwork, and/or photos verifying <br /> corrections <br /> • Operator's certification <br /> Inspection Date: December03, 2019 Inspected By: Stacy Rivera <br /> Facility Address: 3032 E WATERLOO RD CERS ID,* 10180877 <br /> I certify under penalty of law that; <br /> 1 * i have corrected the violations specified In the inspection Report from the above-mentioned inspection date. <br /> 2. 1 have personally examined the following documentation submitted as proof of compliance FOR EACH VIOLATION <br /> and I belietre the information to be true, accurate, and complete: <br /> Photos aperwork Z-'-tement <br /> 3. 1 am authorized to submit this certification on behalf of the Respondent, <br /> 4, 1 am aware that there are significant penalties for submitting false information, including the possibility of a tine <br /> and/or imprisonment for known violations. (HSC 2 V <br /> 91 ) <br /> Name: 0� � TrEle: d W <br /> Signature: Date: 2,6 <br />