Laserfiche WebLink
FEFeb, 22. 201ON. 4:.01PM WI 4 <br />MS TANK LINES No. 4721 P. 2 0021001 <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />600 East Main Street, Stockton, CA 95202-3029 <br />Telephone: (209) 466-3420 Far: (209) 468-3433 Web: www.slgov. j2hd <br />=111 11,11111 ii! Nerple-1 111! 11. 1 11 1 <br />Any violations noted in the "Notice to Comply" In the attached Inspection Report must be <br />corrected within 30 dgys 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 correctionsto ,ether 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 specified in the inspection Report. <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 of $105 (beginning 8/1/09 the hourly rate will be $115). <br />For this Cel'iif cation t0 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/manifestsAraining records/other appropriate paperwork, and/or photos <br />verifying corrections <br />• operators certification <br />r Inspected :; <br />Address:Facility EPA 00014615-0 <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 documentedon submitted as proof of compliance FOR <br />EACH VIOLATION end i believe the Information to be true, accurate, and complete: <br />Photos Paperwork Statement <br />3. 1 am authorized to submit this certification an behalf of the Respondent. <br />4. lam aware that there are significant penalties for submitting false information, including the <br />possibility of a fine and/or imprisonment for known violations. (MSG 25191) <br />NameN 1 S Title: <br />Sidnat�./i �/� <br />Da�- <br />EHD 22-72409 Rov 09" <br />