Laserfiche WebLink
Teo:STAGY RIVERA Page 2&4 2012-11-15 03:58:55(GMT) 12097626954 From:RAVINDER SINGH <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 600 East Main Street,Stockton,CA 95202-3029 <br /> Telephone.(209)468-3420 Fox.(209)468-3433 Web:www-sieov.oralend <br /> RETURN TO COMPLIANCE CERTIBCATION <br /> Any MINOR violations noted in the'Notice to Comply"in the attached Inspection Report must he <br /> corrected within 30 days of receipt of this inspection. This certification form must be submitted to the <br /> Environmental Health Department(END)address at the top'of this form within 30 days of receipt of the <br /> InspectiomReport. HSC 25404.1.2(c)(1) <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 certifcation and returned to END within 30 days <br /> unless otherwise specified in the Inspection Report. HSC'.25185(c)(3) <br /> Note: All EHD staff time associated with failing to comply bythe 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 recordslother appropriate paperwork, and/or photos <br /> verifying corrections <br /> • Operator's certification <br /> Inspection Date: t0i.//7/ — Inspected By:Stacy Rivera <br /> FacilityAddress:Je'�-- (,_N Zt'R, �/ EPA ID#: <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 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 /> possibilityof afine and/or imprisonment for known violations. (HSC.25191) <br /> Name.;'24urfflAF,Z >ir/GN TiNe: 10*fW'*Z;'-,Ce <br /> Signature: Date: /r /Isk <br /> EH0.22.02.005 R"W/11 <br />