Laserfiche WebLink
1.2/21/2007 12:52 2094640138 ENVIRONMENTAL HEALTH PAGE 01/01 <br />SAN T�NJOA,QUIN COCTN'TY <br />iRC1NMF'N".CAL Nr_.m_, H DEPARTMENT <br />304 Last W ober Avenue, P floor, stockton, CA. 95202- 270 �r lchd <br />relephone. (209) 46R.3420 Fnx: (209) 46$-3433 Web: www.s �, 0. r�— <br />RETURN TO COMPLIANCE CERTIFICATION <br />Any MINOR violations noted in the "Notice to Comply" in the attached inspection report must be <br />corrected. witkwin 30 da 5 of rn forni must be submitted to the <br />eceipt of this inspection. This ee f safo m within 35 days of receipt of the <br />Environmental Health Department (EITD) address at the top . <br />inspection report. <br />All corrections to other violations noted in the attach.edstificatioction n and report turned o El'ID ContinuationForm, <br />60 �dar s <br />disputes to any violations, are to be submitted using the <br />unless otherwise speci .fled in the 1R. <br />For this certification to be Complete the operator of the will be taken for each violation <br />ust include: <br />• A. statement documenting what corrective actions were taken <br />Copies of sample results/rrianifests/trai.ning records/other appropriate paperwork, and/or photos <br />verifying corrections <br />operatoFs certification <br />Inspection Date: <br />Inspected By: <br />Facility ,Address: � yd7 �,r�.�, Cho <br />EPA iD#: C� 0pzs5 <br />1, certify under penalty of law that: <br />peci.fted in the inspection Report from the above-mentioned <br />1. I have corrected the violations s <br />inspection date. <br />I have personally examined the following documentation submitted as proof. of compliance FOR <br />2. P <br />EAC// VIOLATION and I believe the information to be true, accurate, and complete: <br />Photos �raperwor'k �Statcrncnt <br />3. I am authorized to submit this certification. on behalf of the Respondent. <br />4. 1 am aware that there are. significant penalties for suhmolati.ons,l(HSC 2S 19 1) <br />including the <br />possibility of a line and/or imprisonment for known <br />Name: Czsliyul6 <br />Date: /Z Zl 07 <br />Si <br />EHD 22-02-005 Rev 12-04 <br />