Laserfiche WebLink
• <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 600 East Main Street,Stockton,CA 95202-3029 <br /> Telephone:(209)468-3420 Fax:(209)468-3433 Web:www sieov.or¢lehd <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 35 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 60 days <br /> unless otherwise specified in the IR. <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 /> ® Operator's certification <br /> F <br /> Date: /o// yw S InspectedBy: 2AY vont F1- z25= <br /> dress: S/S N��/ nog✓� EPAID#: eA aao� 3 i-E I certiy 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 /> ion <br /> as <br /> roof of <br /> 2 1 have personally EACH VIOLATION and examined <br /> bethe lieve the information oowing tbe true, accuratepaand completeliance FOR <br /> Photos ✓ Paperwork Statement <br /> 3. I am authorized to submit this certification on behalf of the Respondent. <br /> 4. 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 /> Title: ��2<<idoDL SYPEZ v1 s a2 <br /> Name: u �l lull�2 c <br /> Signature: Date: <br /> EHD 22-02-005 Rev 05/07 --- ----_ " "- <br />