COMPLIANCE INFO_PRE 2019 - Laserfiche WebLink

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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 600 Esst Main Street, Stockton,CA 95202-3029 Telepl one: (209)468-3420.Fax:(209)468-3433 Web:WMnyAgov.or -1d RETUiN TO COMPLIANCE CERTIFICATION Any MTNOR violations noted in the "Notice to Comply" in the attached inspection rcpart must be corrected within.30_days of receipt of this inspection. This certification form must be subm:tted to the Environmental Health Department(EHD) address at the top of this form within 35 days of receipt of the inspection report. All corrections to other viol tions noted in the attached inspection Report (ZR) or Cottinuat.on Form, or disputes to any violations, c to be submitted using this certification and returned to "fID Nri.thin 60 days unless otherwise specifiedi the IR. For this celrtlficatl n t0 be CO'1Tlpiete the operator of the site must include: 0% A statement documenting what corrective actions were taken or will be taken for ea.-h violation * Copies of sample rsults/manifests/training records/other appropriate paperw)ri.c, air d/or photos verifying corrections * Operator's certification c + � Inspected Inspection Date: G^ . Facility address: �, t'h c' EPS i..D#,: GASZ �'� I certify under penalty f law that: I have corrected the violations specified in the Inspection Report from the above-in,mtioned inspection date. 2. l imve personally e�amincd the following documentation submitted as proof if compliance POR- - 'EACH VIOLATION and I believe the information to be true, accurate, and complete: Photos PaperworkStat n nt 3•. lam Authorized to gubmit this certification on behalf of the Respondent. 4. I am aware that the e are significant penarties for submitting false information, incl ding the possibility of a rnc�,gnd/or imprisonment for known violations. (FISC 25191) N Title: aXne:__f6t Signature: _ .Date: