Laserfiche WebLink
SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 600 East Main Street; Stockton, CA 95202-3029 <br /> Telephone:(209) 468-3420 Fax:(209) 468-3433 Web:www'.$i^Q°rQ <br /> RETURN TO COMPLIANCE CERTIFICATION <br /> Any MINOR violations noted in the "Notice to CompiY" In the attached Inspection Report must be <br /> corrected within 30 days of receipt of this inspection- This certification farm must be submitted to the <br /> Environmental Health Department (EHD) address at the top of this form within 30 days of receipt of the <br /> Inspection Report. <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 3D days <br /> unless otherwise specked in the Inspection Report. <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 resultslmanifestsltraining recordslother appropriate paperwork, and/or photos <br /> verifying corrections <br /> . operator's certification 5 .a 20 L) <br /> ! <br /> Inspection DateInspected By:�A.C�Ni���. �`�j�f'sLr�►n� <br /> Date: a l0 <br /> I <br /> 1 Fa <br /> cili Address:lod V � PA Ib# C� �- 000 <br /> I certify under penalty of law that: <br /> corrected the violations specified in the Inspection Report from the above-mentioned <br /> 1. 1 have <br /> i <br /> inspection date. <br /> 2. 1 have personalty examined the following documentation submitted as proof of compliance FOR <br /> EACH VIOLATION and I believe the information to be true, accurate, and complete: <br /> photos Paperwork Statement <br /> 3, l am authorized to submit this certification on behalf of the Respondent. <br /> 4. lam aware that there are significant penalties for submitting false information, including the <br /> possibility of a fine andlor imprisonment for known violations: (HSC 25191) <br /> Name: �Pa�e,�>� L� '^ �-- Title_ 6) B.IE ' <br /> Date: ' l d <br /> Signature: <br /> kc zr� ern . <br /> EH E 22-02-005 Raw 10109 <br />