Laserfiche WebLink
SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT ���'��® <br />1868 East Hazelton Avenue, Stockton, California 95205-6232 or /ehd R <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: j— -g— <br />RETURN TO COMPLIANCE CERTIFICATION inn EONMENTALIHEALTH <br />Any MINOR violations noted in the "Notice sns inspeto ction. This the <br />certificafionInspection <br />must beReport <br />subm submitted to the <br />corrected within 30 days of receipt oft P <br />Environmental Health Department (EHD) address at the top of this form within 30 days of receipt of the <br />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 <br />disputes to any violations, are to be submitted using this certification and returned to EHD within 30 days <br />unless otherwise specified in the Inspection Report. HSG 25185(c)(3) <br />Note: All EHD staff time associated with failing to comply by the above noted dates will be <br />billed at the current hourly rate. <br />For this certification t0 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 records/other appropriate paperwork, and/or photos <br />verifying corrections <br />• Operator's certification <br />Inspection Date: August 20, 2013 <br />Inspected By:Aris Cacapifi <br />Facility Address: 6421 Capitol Ave. Lodi, CA _ EPA ID#: CAL000346851 <br />I certify under penalty of law that: <br />1. I have corrected the violations specified in the Inspection Report from the above-mentioned <br />inspection date. <br />proof of <br />f 2� 1 have personally examined thefollowing he information totbe'true, accurate, on submitted and complete: <br />pliance FOR <br />`�' EACH VIOLATION and I believe <br />Photos _Paperwork _______.Statement <br />3. lam authorized to submit this certification on behalf of the Respondent. <br />4. I am aware that there are significant fores for known violations. false (HSC25191) information, including the <br />possibility of a fine and/or imprisonment <br />Name: H AKN - S f X16 Title: <br />Sicanature <br />EHD 22-02-005 Rev 04/19/12 <br />rl^- <br />Date: P � ?) 3 <br />