Laserfiche WebLink
} 4; ' Environmental Health Department <br /> SANCOUNT ' <br /> RETURN TO COMPLIANCE CERTIFICATION <br /> Any MINOR violations noted in the`Notice to omplV' in the atkeched Inspection Report must be cor wi hin 30 days of <br /> receipt of this Inspection, This cerlifiCation form must be submitted to the E rrvi rori mental Health Department (EHD) address at <br /> the bottom of this 10x within 30 days of receipt of the fnspecfion Report. HSC 5404.12�,c)(f) <br /> All corrections to other violations noted in the attached Inspection Report (1R)or Continuation Form, or disputi�s to any <br /> violations, are to b� submitted using this certification and returned to EHi]within 30 days unless otherwise specified In the <br /> Inspection Report. HSC 25185(c)(3) <br /> Note: All EHD staff time assnalated with faliing to comply by the alcove noted dates will be <br /> billed at the current hourly rate. <br /> For this fortification to be complete, the operator of the site must include; <br /> A statement documenting what corrective actions were taken or vAll be taken for each violation <br /> Copies of sample resultslmanifestsftraining recordslather appropriate paperwork, and/or photos veriFyIng corrections <br /> Operator's cel icafion <br /> Inspection~ Date: September 18, 2020 inspected By: ROBERT LOPEZ <br /> Facility Address: 2925 E Myrtle St, Stockton CERS U. 10145343 <br /> I certify under penalty of law that; <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 1/IOLATION <br /> and I believe the information to be true, accurate, and complete; <br /> + Photos-Paperwork y--stialement <br /> 3, 1 am authorized to submit this certification on behalF of the Respondent. <br /> 4. I am aware that thele are significant panaltie� for submitting false information, including the possibility of a fine andh <br /> imprisonment for known violations. {HSC 25191) <br /> Name: Title: <br /> Signature: Date: � � <br />