COMPLIANCE INFO_2008 - Laserfiche WebLink

Home Browse Search

SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 600 Fag Main Street Stockton,CA 95202-3029 , Telephone:(209)468-3420 F=(209)468-3433 Web.mm,dm2mkhd RETURN TO COMPLIANCE CERTIFICATION Any hRM violations noted in the"Notice to Comply"in the attached Inspection Report must be cont a9wwithin 39&3m 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 35 days of receipt of the Inspection Report. All 20=9=12 other t2lafigz 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 mdua 20 days unless otherwise specified in the Inspection Report. Note: All EEID staff time associated with failing to comply by the above noted dates will be billed at the current hourly rate($98). For this certification to be complete the 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 recordslother appropriate paperwork,and/or photos verifying corrections • Operator's certification Inspection Date: Inspected By: Q dUT Facility Address: N CW .(A- EPA IN: QAA02*MoLi 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. 4. 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: Lis Title: law V 3 Signa turd,: Date: -0 ® EHD 22-02-005 Rev H/07