Laserfiche WebLink
• SAN JOAQUIN COUNTY � <br />ENVIRONMENTAL HEALTH DEPARTMENT,. <br />CA 95202-3029 � <br />600 East Main Street, Stockton, ,�� 47V <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.segov.orq/ehd <br />l�N 2 7 <br />O1� <br />RETURN TO COMPLIANCE CERTIFICATION .7tw», ',� � 4LTH <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 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 certification and returned to EHD within 30 days <br />unless otherwise specified in the Inspection Report. <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 of $105 (beginning 8/1/09 the hourly rate will be $115). <br />For this certification t0 be compete 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: Inspected By: Steve 6� Q.P0.,�iaC. C <br />Facility Address: "1 p h E �o" EPA ID#: cA)_ Cf)Q15(0`77 6�, <br />I certify under penalty of law that: <br />1. 1 have corrected the violations specified in the Inspection Report from the above-mentioned <br />inspection date. <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 Paperwor 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 <br />possibility of a fine and/or imprisonment for known violations. (HSC 25191) <br />Name: S`_k__6C-'t3 �_cvj Title: <br />Sianature: Date: <br />EHD 22-02-005 Rev 06/09 <br />