Laserfiche WebLink
0 <br />t ri <br />San Joaquin County <br />Environmental Health Department <br />1868 East Hazelton Avenue, Stockton, California 9520EN3A RON �EEr <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sioov.oru/e <br />• • • <br />Any MINOR violations noted in the 'Notice to Comply" in the attached Inspection Report must be corrected within 30 days of <br />receipt of this inspection. This certification form must be submitted to the Environmental Health Department (END) address at <br />the top of this form within 30 days of receipt of the Inspection Report. HSC 25404.1.2(c)(1) <br />All corrections to other 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. HSG 25185(c)(3) <br />• i . .ry • . • ,. �. •c <br />billed at the current hourly rate. <br />For this certification to 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 recordslother appropriate paperwork, and/or photos verifying corrections <br />Inspection t-2017 Inspected By <br />I certify under penalty of law that: <br />I'Mol 01111 OM II <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 and <br />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. 1 am aware that there are significant penalties for submitting Use information, including the possibility of a fine and/or <br />imprison ent for known violations. (HSC 25191) <br />Na vt z t e -t Title: kY1 L/G-� <br />signat e: �" ate: 6 l l7 <br />