Laserfiche WebLink
SAN JA A OU IN Environmental Health Department <br /> ;-r 'r Y <br /> • Gr�+ otr► � SS grow3 hate . <br /> RETURN TO COMPLIANCE CERTIFICATION <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 Environmentol Health Department (EHD) address <br /> at the top of this form within 30 bays of receipt of the Inspection Report. HSG 25404. 1 .2(0)(1 ) <br /> All correClions to ather.yioiations noted in the attached Inspection Report (IR) or Continuation Form, or disputes to any <br /> violations, are to be sup witted using this certification and returned to EHD wi1hin .a0_days unless otherwise specified in the <br /> Inspection Report. Hat; 25186(0)(3) <br /> Nate: All EHD staff time associated with failing to cotnply ' by the above noted dates will be <br /> billed at the currant hourly rate. <br /> For this certification to be complete , thee 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/manifestsitraining records/other appropriate paperwork, and/or photos verifying <br /> corrections <br /> Operator's certification <br /> Inspection Date: ,inns 05 , 2019 inspected ley: CLAUDIA MUR4 <br /> Facility Address: 23408 E ARTHUR RD, ESCALON <rERS 1 ©: 10180513 <br /> certify under penalty of law that; <br /> 1 - I have corrected the violations specifiad in the Inspection Report from the sbovemmentioned inspection date. <br /> 2. 1 have personally examined ft 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 c 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 possibility of a fine <br /> and/or imprisonment for known violations. (HSC 25191 ) <br /> Name: _ lekh KI 1 � 0, K e Title: 0 W 41 <br /> Signature : 65:�p - ' --T— Date : t5� it <br /> ED <br /> REGE . . <br /> JUS! <br /> 1868 E. Hazelton Avenue { Stockton , California 952051 T 209 468-34201 F 209 484.013$ 1 www. sjcehd,com <br />