COMPLIANCE INFO_PRE 2019 - Laserfiche WebLink

Home Browse Search

!' r SAN JOAQUIN COUNTY r-0 r: ENVIRONMENTAL HEALTH DEPARTMENTsT � k, 600 East Main Street, Stockton, CA 95202-3029 vy" " -� ` Teleph ne:(209)468-3420 Fax:(209) 468-3433 Web:www.sigov.orq/ehd 1uN 03 zoo RIET RN TO COMPLIANCE CERTIFICATION' Any MINOR violations not in the "Notice to Comply" in the attached Inspection Report must be corrected within 30 days o receipt of this inspection. This certification form must be submitted to the Environmental Health De rtment (EHD) address at the top of this form within 30 days of receipt of the Inspection Report. All corrections to other violations 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 within 30 days unless otherwise specifiedlin the Inspection Report, Note: All EHD s ff time associated with failing to comply by the above noted dates will be billed at t e current hourly rate. For this certification t0 be Complete the operator of the site must include: • A statement d umenling what corrective actions were taken or will be taken for each violation • Copies of sample res Its/manifests/training records/other appropriate paperwork, and/or photos verifying corrections • Operator's certificatio Inspection Date: �17 9-0)U Inspected-By: 81*q Cy � r V-e r Gk Facility Address:! 5-)5- w /I T''�T '7rg C y EPA ID#: 004aqV 1 7k a?8 76 1 certify under penalty of law that: 1. 1 have corrected thqI violations specified in the Inspection Report from the above-mentioned inspection date. i 2. 1 have personally a mined the following documentation submitted as proof of compliance FOR EACH VIOLATION nd I believe the information to be true, accurate, and complete: Photos Paperwork 7\ Statement 3. 1 am authorized to s bmit this certification on behalf of the Respondent. 4. 1 am aware that ther are significant penalties for submitting false information, including the possibility of a fine a d/or imprisonment for known violations. (HSC 25191) Name: _bUL / i Title Signature: / Date: 3 / EHD 22-02-005 Rev 10/09 Td WdZb:le 0TOE 20 f 'ON Xtd WOdd