Laserfiche WebLink
v. P1.yes �l caf 10 2013 -OB -1 A J3.01 .35 (GMT) 16663^_198616 W,O JO aha .. <br />SAN .JOAQUIN COUNTY F?ECEIVED <br />i.- ?)ENVIRONMENTAL HEALTH DEPARTMENT <br />600 East Main Street, Stockton, CA 95202-3029 (� <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.s' gK.._org/ehd VA • G V 3 20 4 <br />r -... - <br />HEA_' <br />HEALTH pip°���MENA <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(c)(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/manifests/training records/other appropriate paperwork, and/or photos <br />verifying corrections <br />• Operator's certification <br />Inspection Date: d /13 Inspected By: Stacy Rivera <br />Facility Address: �331>uC't�-.. C..J-" _ _j _ EPA ID#: } 220 Lam-% � <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 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 tel Paperwork _ v Statement <br />3. lam authorized to submit this certification on behalf of the Respondent. <br />4, lam 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 />4 � <br />Name: Title:� <br />� � - <br />Siang Lire: 1 1 1 0 1 11 ;I i 1 It Date: b� Li' iL� <br />OR) 22-02-0(A Rev W111 <br />