Laserfiche WebLink
SAN JOAQUIN COUNT':( <br />R IVSD <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />1863 East Hazelton Avenue, Stockton, California 95205-6232 MAY 2L Z013 <br />Te/ep,`mne: (209) 468-3420 Fax: (209) 468-3433 Web: www.siaov.orq/ehd <br />SAN JOAQUIN COUNTY <br />HEALTH DEPARTMENT <br />RETURN TO COMPLIANCE CERTIFICATION <br />Any MINOR violations noied in the "Notice to Comply" in the attached Inspection Report m ust 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. HSC 25404.1.2(c)(1) <br />All corrections to other vioiations noted in the attached Inspection Report (IR) or Continuation Form, or <br />disputes to any violaticns, are to be submitted using this certification and returned to EHD within 30 days <br />unless otherwise :specified in the Inspection Report. HSC 25185(c)(3) <br />Note: All EHD staff 1inje associated with failing to comply by the above noted dates will be <br />billed at the current hourly rate. <br />For this Cert-ification 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 <br />verifying corrections <br />• Operator's certification <br />Inspection Date: r ��� Inspected By:Jeffrey Wong <br />Facility Address: Akov-�P, EPA ID#: CALWOSA7i J <br />I certify under penalty of law that: <br />I have corrected the violations specified in the Inspection Report from the above-mentioned <br />inspection date. <br />I have peKsonally 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 ,/ Paperwork Statement <br />3. 1 am authorized to summit this certification on behalf of the Respondent. <br />^,. I 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:. 71 N lL'y l`( iJ 51e1-/ Title: <br />Signature:` 6 Date: �? <br />EHD 22-02-005 Rev 04119112 <br />