Laserfiche WebLink
San Joaquin County RECEIVED <br />Environmental Health Department <br />1868 East Hazelton Avenue, Stockton; California 95205-6232 FEB.09 2017 <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www sigov.orglend <br />RETURN TO COMPLIANCE CERTIEMIRIVMKNTAL HEALTH <br />DEPARTMENT <br />Any MINOR violations noted in the "Notice to Comply" in the attached Inspection Report must be corrected within 30 days of <br />receipt 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 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 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: October 31, 2016 <br />Inspected By: MICHELLE HENRY <br />Facility Address: 15999 W CORRAL HOLLOW RD, Tracy CERS ID: 10154767 <br />I certify under penalty of law that. <br />1. 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 Paperwork 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: Title <br />Signature: <br />