Laserfiche WebLink
0 SAN JOAQUIN COUNTY 10- <br /> ENVIRONMENTAL HEALTH DEPARTMENT k <br /> 600 East Main Street,Stockton,CA 95202-3029 <br /> Telephone:(209)468-3420 Fax.(209)468-3433 Web:www.si ovor ehd <br /> RET TO'COMPLIANCE CERTIFICATION <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. <br /> All corrections to other violations noted in the'attached Inspection Report(IR)-6r)C6n"tinuati6n Form, or,. <br /> disputes to any Violations, are tobe submitted using this certification and returned to EHD'within 30 days <br /> unless otherwise specified in the Inspection Report. <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 r Complete the operator of the site must include: <br /> ® A statement documenting'what corrective actions were taken or will be taken for each violation <br /> « Copies of sample results/manifests/training records/other appropriate paperwork,and/or photos <br /> verifying corrections =` <br /> • Operator's certification <br /> Inspection Date: 6 !/— ZO`0 Inspected By: " /AgI _ F <br /> Facility Address: d/26 W. komdcq, dv&e, EPA 1 : C id.Op®0!j$9'Z6 <br /> A41j0 A WC 4.. Col `15.73 6 <br /> 1 certify under penalty of law that: <br /> 1. 1 have corrected the violations specified in the Inspection Report from the above-mentioned <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 t0" 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 /> Name: ,Zg' Vs'L6t At WigoZ►o: Title: Mg!d s <br /> Signature: '� Date: 4;A ff 20!0 <br /> EHD 22-02-005 Rev 10/09 <br />