Laserfiche WebLink
San Joaquin County <br />Environmental Health Department <br />1868 East Hazelton Avenue, Stockton, California 95205-6232 <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sigov.orq/ehd <br />RETURN TO COMPLIANCE CERTIFICATION <br />Anv MINOR violations noted in the 'Notice to Complyin the attached Inspection Report must be corrected within 30 days of <br />recent of this inspection. This certification form 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 ccnections 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 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 verifying <br />corrections <br />Inspection Date: June 21, 2017 Inspected By: HAZA SAEED <br />Facility Address: <br />17880 W Schulte Rd, Tracy CERS ID: 10146189 <br />I certfy, under penalty of law that: <br />I 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 VIOLATION <br />and I believe the information to be true, accurate, and complete: <br />Photos X Paperwork X Statement <br />3. 1 am authorized to submit this certification on behalf of the Respondent. <br />t. I am aware [hat there are significant penalties for submitting false information, including the possibility of a fine <br />and/or imprison ent for known violations. (HSC 25191) O <br />Name: cw,n n r,l 5 Title:/ <br />Signature: Date: 12, Z; of <br />