Laserfiche WebLink
SAN JOAQUIN COUNTY <br /> ENVIRONMENTAa HEALTH DEPARTMENT <br /> 600 East Main Street, Stockton, CA 95202-3D29 <br /> Telephone:(209) 468-3420 Fax: (209) 4683433 Web,www.si o�v.org/e d <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 clays, 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 othi-.3r 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 /> unle�3s 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 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/manifests/training records/other appropriate paperwork, and/or photos <br /> verifying corrections <br /> • Operator's certification <br /> Inspection Date:_ f 44s�lo Inspected By: <br /> Facility Address: '� �` � ��r� z�,. ,, EPA ID#: <br /> d <br /> I certify under penalty of law that: <br /> 1. 1 have corrected the violations specified in the Inspection Report from the above-mentioned <br /> inspection d,nte. <br /> :?. I 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 /> a. I am authori -ed to submit this certification on behalf of the Respondent. <br /> 4, 1 am aware ihat 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: � J d V/' Title: <br /> &4 1. `l <br /> t' <br /> ,signature Date: <br /> a <br /> r� <br /> EHD 77.02.005 Rev 10109 <br />