COMPLIANCE INFO_1995-2006 - Laserfiche WebLink

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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPAR ENT - 304 East Weber Avenue,Yd Floor,Stockton,C k 95202-2708 Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.st¢ov.org[ehd RETURN TO COMPLIANCE CE TIFICATION ,Any MINOR violations noted in the"Notice to Comply"in the att hed inspection report must be - corrected within 30 days of receipt of this inspection. This certificc tion form must be submitted to the Environmental Health Department(EHD) address at the top of this form within 35 days of receipt of the inspection report. All corrections to other violations noted in the attached Inspectioneport(IR)or Continuation Form, or _ disputes to any violations, are to be submitted using this certificati and returned to EHD within 60 days unless otherwise specified in the IR. 7 For this Certification t0 be Complete the operator f the site must include: • A statement documenting what corrective actions uvere tak n or will be taken for eaclr violation • Copies of sample results/manifests/training records/other a propriate paperwork, and/or photos verifying corrections • Operator's certification Inspection Date: Inspec ted By: Facility Address: I certify under penalty of law that: - 1. I have corrected the violations specified in the Inspection port from the above-mentioned inspection date. 2. I have personally examined the following documentation s bmitted as proof of compliance FOR EACH VIOLATION and I believe the information to be tn e, accurate, and complete: Photos Paperwork Statement 3. I am authorized to submit this certification on behalf of the Respondent. 4. I am aware that there are significant penalties for submittin false information, including the possibility of a fine and/or imprisonment for known violations. (HSC 25191) Name: Title Sigriat46- Date EHD 22-02-005 Rev 12-04