Laserfiche WebLink
S J QUIN COUNTY <br />ENviRo N HEALTH DEPARTMENT <br />600 East in eet, Stockton, CA 95202-3029 <br />Telephone: (209) 468-3&a (�209) 468-3433 Web: www.sigov.org/eh <br />Y, <br />ex" <br />RETURN TO COMPLIANCE CERTIFICATI <br />Any MINOR violations noted in the "Notice to Comply" in the attached inspection report must <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 35 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 60 days <br />unless otherwise specified in the IR. <br />For this eertification to beCOMplete 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/manifests/training records/other appropriate paperwork, and/or photos <br />verifying corrections <br />• Operator's certification <br />Inspection Date: ZZ )07 Inspected By: t OU <br />Facility Address: qqqq o,. Aab��W EPA ID#: <br />I certify under penalty of law that: <br />1. 1 have corrected the 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 VIOLATION and I believe the information to be true, accurate, and complete: <br />Vel-�Photos y' Paperwork Statement <br />4. 1 am aware that there are simificant penalties for submitting false information, including the <br />possibility of a fine and/or imprisonment for known violations. (HSC 25191) <br />Name: H Gill J -e- Z- Title: 0 C <br />SiLynature: <br />U T -TT% '),I fill AA C T3. AC /A7 <br />Date: <br />