COMPLIANCE INFO_2002-2009 - Laserfiche WebLink

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SAN JOAQUIN COUNTY WENVIRONMENTAL HEALTH DEPARTMEMP - A 600 East Main Street, Stockton, CA 95202-3029 Telephone:(209)468-3420 Fax. (209)468-3433 eb: .siaov.or /q ehd RETURN TO COMPLIANCE CERTIFICATION Any MINOR violations noted in the "Notice to Comply" in the attached Inspection Report must-VO-- corrected within 30 dans of receipt of this inspection. This certification form must.be submitted to the Environmental Health Department-(EHD) address at the top of this form within 30 days of receipt of the Inspection Report. All corrections to other violations noted in the attached Inspection Report (IR)_or Continuation Form, or disputes to any violations, are to be submitted using this certification and returned to EHD within 30 days unless othe ise specified in the Inspection Report. - Note: All EHD staff time associated ifailing comply theabove noted dates will be billed current hourly rate o 105 (beginning 8/1/09 the hourly rate will be$115). C this certificationbe completethe operator of the site-must include: • A statement documenting what corrective actions were taken or will be taken for each violation • Copies of sample results/manifests/training records/other appropriate paperwork, and/or photos verifying corrections • Operator's certification Inspection : Inspected : Facility : I certify under penalty of law that: 1. 1 have corrected the violations specified in the Inspection Report from the above-mentioned inspection date. 2. 1 have personally examined the following documentation submitted as proof of compliance FOR EACH VIOLATION and I believe the information to be true, accurate, and complete: Photos Paperwork Statement 3. 1 am authorized to submit this certification on behalf of the Respondent. . 1 am aware that there are significant penalties for submitting false information, including the possibility of a fine and/or imprisonment for known violations. (HSC 25191) Name: Title: Signature: Date: EHD 22-02-005 Rev 06/09