Laserfiche WebLink
Im. <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />1868 East Hazelton Avenue, Stockton, California 95205-6232 <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sigov.org/ehd <br />S t <br />Any MINOR violations noted in the "Notice to Comply" in the attached Inspection Report must be <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 30 days of receipt of the <br />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 <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. 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 t0 be%'nmplete the operator of the site must include: <br />• A statement documenting what correcctions were taken or will be taken for each violation <br />• Copies of sample results/manifests/trrecords/other appropriate paperwork, and/or photos <br />verifying corrections <br />• Operator's certification <br />Inspection Date: July 24, 2013 Inspected By: Elena ME: FMI 1"(0n`%BVtD <br />Facility Address: 983 Moffat Blvd <br />I certify under penalty of law that: <br />EPA ID#: 201 <br />1. 1 have corrected the violations specified in the Inspection Report from the <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 />���L�a� G. II �1rV _' .t/i r-'-1 <br />Sianaturefc+m id o/A ( Date: <br />EHD 22.02.005 Rev 04/19/12 <br />