COMPLIANCE INFO_2006-2008 - Laserfiche WebLink

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I i SAN JOAQUIN COUNTY ir1J MENTAL Hrr.ALTH DEPARTMENT 600 sin Street, swckton, CA 95202.3029 T'etephoae: (209) 20 Fax: (249) 468-3433 Wob.- 11 3y tot ii 1? 5) 1. Any M2M violations noted in the " ce to Comply" in the attached Inspection Report must be 22M2zM torr hdUdiva of receipt of inspection. This certification form must be submitted to the Environmental Health Department (E , address at the top of this form within 35 days of receipt of the Inspection Report. ..� Note: All EHD staff time associated';] the current hourly rate (SN). For this certification to be!} • A statement documenting whai • Copies of sample results/mani verifying corrections •Operator's certification the attached Inspection Report (IR) or Continuation Form, or ted using this certification and returned to tin 30 days L Report. failing to comply by the above noted dates will be bill at piece the operator of the site must include: tive actions were taken or will be taken for aach violations ining records/other appropriate paperwork, and/or photos Inspection Date: j Inspected BGy: 2.Ev[D*: Facility Address: I certify under penalty of law / 1. I have corrected the violations ocified in the Inspection Report from the above-mentioned inspection date. 2. I have personally examined EACH VIOLATION and I 3. I am authorized to submit this 4. I am aware that there are sig possibility of a fine and/or in Name: 11a' Ukj MAI l_W 11F, • F.HI)'7_n,)_nA1S my 11 /117 90 39ad owing documentation submitted as proof of compliance FOR the information to be true, accurate, and complete- -Paperwork statement on behalf of the Respondent. penalties for submitting false information, including the hent for known violations. (HSC 25191) ✓�fto kls6 itle: ��'+o fqa'� s 8L9L5E860Z 8E:L0 800Z/TZ/Z0