Laserfiche WebLink
• 0 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 600 East Main Street, Stockton, CA 95202-3029 <br /> Te1ephone.4209)_468-342QFax.(209).4.68-3433 Web:wwuu.si ov..or /ehd <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 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 /> Ali 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. <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 /> a Copies of sample results/manifests/training records/other appropriate paperwork, and/or photos <br /> verifying corrections <br /> • Operator's certification <br /> Inspection-Date: 0.3 q //o _ Inspected By: Rctu 4 ,tel,e. <br /> Facility Address:1119- ti ,h -�1,�;;e EPA I-D#: � Ll 9 0tf;.s 19 z I <br /> s-fo-a,i-ta C,4 <br /> I certify under penalty of law that: <br /> 1 I 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 v 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 <br /> possibility of a fine and/or imprisonment for known violations. (HSC 25191) <br /> Name: =, Title: t77,��. y,a 4G..�c... � <br /> Signature: ��. Date: <br /> EHD 22-02-U05 Rev 10109 <br />