Laserfiche WebLink
• <br />JUL 07 20111 <br />San Joaquin County <br />Environmental Health Department _ qq L <br />1$fi8 East Hazelton Avenue, Stockton, California 95205 �32 <br />pe rt t �,.: ��t ,4 L H E,nI T I <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www. siaov. ora/eb&'',A <br />RETURN TO COMPLIANCE CERTIFICATION <br />Any MINOR violations noted in the "Notice to Comply" in the attached Inspection Report must be coryected within 3Q days of <br />receipt of this inspection. This certification form must be submitted to the Environmental Health Department (EHD) address <br />at the top of this form within 30 days of receipt of the Inspection Report. HSC 25404.1.2(c)(1) <br />All corrections to othgr violations noted in the attached Inspection Report (IR) or Continuation Form, or disputes to any <br />violations, are to be submitted using this certification and returned to EHD within 30 days unless otherwise specified in the <br />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 to be complete, the operator of the site must include: <br />Astatement documenting what corrective actions were taken or will be taken for each violation <br />Copies of siample resultsimaniFestsltraining records/other appropriate paperwork, and/or photos verifying <br />corrections <br />Operator's certification <br />Inspection Date: September 23, 2013 <br />Facility Address: 2072 W YOSEMITE AVE <br />I certify under penalty of law that: <br />Inspected By: Elena Manzo <br />CERS ID: 10181669 <br />1. 1 have corrected the violations specified in the Inspection Report from the above-mentioned inspection date. <br />2. 1 have personally examined the following documentation submitted as proof of compliance FOR EACH VIOLATION <br />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. lam aware that there are significant penalties for submitting false information, including the possibility of a fine <br />and/or imprisonment for known violations_ (HSC 25191) <br />Name: 4/ #Z:, Title: <br />Signature:Date: <br />7Z�l <br />/ I �jam,, b - r= , ,r <br />U111 <br />jl�7 <br />tic <br />Z'd OOL9VZ96OZ do4S Noinb deo:Z I. L I• LO Inr <br />