Laserfiche WebLink
SAN JOAQumrCOUNTY <br /> RECEIVED <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 600 East Main Street,Stockton,CA 95202-3029 N O V 0 2 2012 <br /> Telephone:(209)468-3420 Faz:(209)468-3433 Web:www.sigov.org/ehd <br /> ENVIRONMENTA ICEALTH <br /> RETURN TO COMPLIANCE CERTIFICATION <br /> Any MINOR violations noted in the"Notice to Comply"in the attached Inspection Report must be <br /> corrected within 30 days of receipt of this inspection. This certification form must be submitted to the <br /> Environmental Health Department(EHD)address at the top of this forth within 35 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 30 days <br /> unless otherwise specified in the Inspection Report. <br /> Note: All I;I3D staff time associated with failing to comply by the above noted dates will be billed at <br /> the current hourly rate($122). <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: 10 I 1 C 1 2 O� 2 Inspected W OY� <br /> Facility Address:2°t , I, Avropt4 S& . EPA ID#: C AZ-0o6 2.21363 <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 /> 2. I have personally examined the following documentation submitted as proof of compliance FOR <br /> EACH VIOLATION and I believe the informa ' to b=Statement and complete: <br /> hotos Paperwork <br /> 3. I am authorized to submit this certification on behalf of the Respondent. <br /> 4. I am aware that there are significant penalties for submitting false information,including the <br /> possibility of a fine and/or imprisonment for known violations. (HSC 2519 1) <br /> Name: �Q ( 'f—CC-,/\ Title: QT2t ,YL <br /> Signature: ate: 16 24 1261 <br /> EHD 22-02-005 Rev 08/10 <br />