Laserfiche WebLink
SAN J OAO U I N Environmental Health Department <br /> RETURN TO COMPLIANCE CERTIFICATION <br /> Any MINOR violations noted in the"Notice to Comply'in the attached Inspection Report must be connected within 30 days of <br /> receipt of this inspection. This certification farm must be submitted to the Environmental Health Department(EHD)address <br /> at the top of this form within 30 days of receipt of the 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 disputes to any <br /> violations,are to be submitted using this certification and returned to EHD within 30 days unless otherwise specified in the <br /> Inspection Report. HSC 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 to be complete, the operator of the site must include: <br /> A statement documenting what connective actions were taken or will be taken for each violation <br /> Copies of sample results/manifests/tmining recardsrother appropriate paperwork,and/or photos verifying <br /> corrections <br /> Operalofs certification <br /> Inspection Date: July 10, 2018 Inspected By: NICHOLAS LOEHRER <br /> Facility Address: 601 Darcy Pkwy, Lathrop CERS ID: 10739470 <br /> 1 certify under penalty of law that: <br /> 1. I have connected the violations specified in the Inspection Report from the above­mentioned inspection date. <br /> 2. 1 have personally examined the following documentation submitted as proof of compliance FOR EACH VIOLATION <br /> and 1 believe the information to be true,accurate,and complete: <br /> Photos Paperwork X/ 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: CV,,,,kw�emeka "br,.y't O'A'nze Title: Env;.ontiankal Lor.pl:nncc M�n.Ser <br /> Signature: L-- Date: 9 <br /> 1868 E.Hazelton Avenue I Stockton,California 95205 1 T 209 468-34201 F 2094640138 1 www.sjcehd.com <br />