Laserfiche WebLink
SAN J a A Q U I N Environmental Health Department <br />COUNTY <br />RETURN TO COMPLIANCE CERTIFICATION <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 Farm, 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 takers for each violation <br />Copies of sample results/manifests/training recordslother appropriate paperwork, and/or photos verifying <br />corrections <br />Operator's certification <br />Inspection Date: August 15, 2018 Inspected By: <br />Facility Address: 3480 NAGLEE RD, TRACY CERS ID: <br />LYDIA BAKER <br />10185175 <br />I certify under penalty of law that: <br />1. 1 have corrected the violations specified in the Inspection Report from the above-mentioned inspection date. <br />1 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: Date: <br />1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-34201 E 209 454-0138 1 www.sjcehd.com <br />