Laserfiche WebLink
06/11/2013 10:50 2093344684 ###146 F.001 /002 <br /> SAN JOAQUIN COUNTY <br /> ENvIRONMENTAL HEALTH DEPARTMENT <br /> 1868 East Hazelton Avenue,Stockton,California 95205-5232 <br /> Telephone:(209)468-3420 Fax:(209)468-3433 Web:wwwsioov.org/ehd JUN 11 2013 <br /> HEALTH DEPARTMENAL <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. 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 certification and returned to EHD within 30 days <br /> unless otherwise specified in the Inspection Report. HSC 25185(0)(3) <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 t0 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/manffests/training reeords/other appropriate paperwork, and/or photos <br /> verifying corrections <br /> • Operator's certification <br /> Inspection Date: 3 Inspected By: <br /> Facility Address: *( dl <br /> PA 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 t✓'Statement <br /> 3. lam authorized to submit this certification on behalf of the Respondent. <br /> 4. I am aw hat there are signifi penalties for submitting false information, including the <br /> possi ity of fine and/or impri <br /> or <br /> t for known violations. (HSC 25191) <br /> Name: PC Title: <br /> signature. j:;t <br /> Date: 3 <br /> EMD 22-02-005 Rev 04119112 <br />