Laserfiche WebLink
2010-09-15 15:30 Costco #1031 2098258204 >> 2094683433 P 4/17 <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />600 East Main Street, Stockton, CA 95202-3025 <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 Web mw.s" ay.or /ehd <br />RETURN TO COMPLIANCE CERTIFICATION <br />Any MI NOR 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 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 3© days <br />unless otherwise specified in the Inspection Report. <br />Note: All EHD staff time associated with tailing 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 />Copies of sample results/manifests/training records/other appropriate paperwork, and/or photos <br />verifying corrections <br />o Operator's certification <br />Inspection Date: .._... I( <br />Inspected By: i <br />Facility Address, <br />(LI :" EPA ID#: 0 <br />1 <br />I certify underenal � <br />p ty of law that: <br />1. i have corrected the violations specified in the Inspection Report from the above-mentioned <br />inspection date. <br />2. l 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 Paperwork - Statement <br />3. 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 <br />Possibility of a fine and/car imprisonment for known violations. (HSC 25191) <br />Dame: <br />Title: <br />Signature Date: - f <br />EHD 22-02-045 Rev 10109 <br />