Laserfiche WebLink
SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL 14r-ALTH DEPARTMP-NT <br /> 600 East Main Street,Stockton,.CA 95202-3029 <br /> Telephone. (209)468-3420 Fax (200)468-3433 Web:www.sigov.arPJehd <br /> RETURN TO COMPLIANCE CERTIFICATION <br /> Any MINOR violations noted in the"Notice to Comply"in the attached inspection report must be <br /> corrected within 30 dans of receipt of this inspection. This certification form must be submitted to the <br /> Environmental Health Department(EHD)addm" at the top of this form within 35 days of receipt of the <br /> inspection report. <br /> All corrections to other violations noted.in the attached Inspection Report(JR)or Continuation Form, or <br /> disputes to any violations, are to be submitted using this certification and returned to EHD within 60 days <br /> unless otherwise specified in the IR. <br /> For this certification t® be 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: InspectedBy: <br /> Facility Address: IY-01 W EPA 11)#: C1L <br /> I certify wider 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 Lfaperwork 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: Title-, (�e"Jfllck A&V2W�� <br /> Signature: -- Date: '-7/3 <br /> FPT) '7')-A')-nCK P-me A91(17 <br />