Laserfiche WebLink
. SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 600 East Main Street, Stockton, CA 95242-3029 <br /> Telephone-(209) 468-3420 Fax: (2a9)458-3433 Wob:y_VSM,siacy.orglettd <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 da s of receipt of this inspection_ This certification form roust 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 certitication and returned to EHD within 30 da s <br /> unless otherwise specified in the Inspection Report. <br /> Note: All END 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 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 /> e Copies of sample resultslmanifests!trainirig records/other appropriate paperwork, and/or photos <br /> verifying correction$ <br /> . Operator's certification <br /> Inspection Date:� Inspected By: P� r�-- • �' <br /> Facility Address= V;uvx <br /> �`L � EPA ID#: bda <br /> 1 certify under penalty of law that: <br /> I have corrected the violations specified in the Inspection Report from the above-mentioned <br /> tnspactiv+i Mate. <br /> 2, 1 have personally 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 aperwork Statement <br /> I3, I 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 i <br /> possibility <br /> of a fine and/or imprisonment for known violations, (HSC 25191) <br /> Name: <br /> Title._ <br /> dwc <br /> Sirgnature: <br /> Date: 61 <br /> EHD 22-02-005 Rev 10109 <br />