Laserfiche WebLink
SAN JOAQUIN COUNTY <br /> EWRONMf_NTAL HEALTH DEPARTMENT <br /> 600 Last Main Street, Stockton, CA 95202-3029 <br /> Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.siQov.or¢Leb <br /> RETURN TO COMPLIANCE CERTIFICATION <br /> Any MINOR violations not�d to the"Notice to Comply" in the attached Tnspection Report trust be <br /> corrected within 30 days of receipt of this inspection. This certification form must be su-bmi tted to the <br /> Environmental Health Department (EHD) address at the top of this form within 35 dais of roceipt of the <br /> Inspection Report. <br /> All corrections to other vioWtions noted in the attached Inspection Report (IR) or Con.inuati m Form, or <br /> disputes to any violations, e to be submitted using this certification and returned to Ii1lD u ithin 30 days <br /> unless otherwise specified itl the Inspection Report. <br /> Note: All EHD staff timessociated with failing to comply by the above noted dates will be bulled at <br /> the current hourly rate ($9R). <br /> For this certificate 11. to be COMPlete the operator of the site must include: <br /> • A statement doeum ntirig what corrective actions were taken or wall be taken for each violation <br /> • Copies of sampler ults/manifests/training records/other appropriate paperwork, anVor photos <br /> verifying correction <br /> a <br /> • Operator's certiFc 'on <br /> ILI <br /> Inspection Daae Inspected By: <br /> P .� <br /> 61 .n D A,����9 . <br /> Facility Address:ess: G.PA ID#: Cr , <br /> I certify under:penalty of law that: <br /> 1. -_I have corrected the Mations specified in the Inspection Report from the abc ve-mEntioncd <br /> inspection date. <br /> 2. I have personally exl mined the following documentation submitted as proof of compliance FOR <br /> EACH VTOLATIOT�and I believe the information to be true, accurate, and co�rnplete: <br /> Photos ______�Paperwork� Statement <br /> �3. I am authorized to submit this certification on behalf of the Respondent. <br /> 4. I am aware that then are signiCcant penalties for submitting false information, inch ding the <br /> possibility of a fine nd/or imprisonment for known violations. (HSC 2519 1.) <br /> Name: <br /> Signature: Date: L/ <br /> FHT 22-n2-005 Rev 11/07 <br />