Laserfiche WebLink
SANJO4QU|N COUNTY <br /> ENVIRONMENTAL HEALTHDEPARTMENT <br /> 6O8East Main Street, Stockton, CA85202'302Q <br /> Telephone:(2OQ)4G8'3420Fax. (209)408'3433Web: <br /> ����l7� K���� 77�� COMPLIANCE ����g�l�QN������77N���� <br /> °==� nv�°~m� � �� ����"°"° =~.��"=~°~~ CERTIFICATION <br /> "����o ���°� <br /> Any MINOR violations noted /n the "Notice to Comply" in the attached Inspection Report must be <br /> corrected within 30 days ofnocmiptofthiminopeot|on. Thhacertifioationfonn!nuetbeoubmittedtotha <br /> Environmental Health Department /EHD>address at the top nfthis form within 38days ofreceipt ofthe <br /> Inspection Report. HSC 25404.1.2(c)(1) <br /> All corrections to other violations noted in the attached Inspection Report UR\orContinuation Form, or <br /> disputes toany violations, are to be submitted using this certification and returned to EHD within 30 days <br /> unless otherwise specified inthe 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 /> or this certification to be comp|e* <br /> e the operator ofthe site must include: <br /> w /\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 /> w Operator's certification <br /> Inspection Date:____ Inspected By:,Stacy-Rivera <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 /> Photos Paperwork Statement <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 <br /> possibility of a fine and/or imprisonment for known violations. (HSC 25191) <br /> Name: Title: J,., ,flt-eUW41 <br /> Sig nature: Date: <br /> / . <br /> -11< �� NL / <br /> v _- - . ~ - , <br />