Laserfiche WebLink
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.sjgov.oreehd <br />RETURNTO 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 />alspLies 14 wm,, rmm I:e to ue S101111ttC(I LSIII�; LHIS CUU111CUL1011 MILL rULjXLHVA1J7_rN <br />unless otherwise specified in the IR. <br />For this certification to be completethe 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 />[MIT M4. <br />mm=� I1 <br />1. 1 have corrected the violations specified in the Inspection Report from the above -mention <br />inspection date. i <br />2. 1 have personally examined the -• <br />documentation submitted as proof of compliance FOR <br />EACH VIOLATION and I believe the iormation to be true, accurate, and complete: <br />Photos Paperwork Statement 4 <br />3. 1 am authorized to submit this certification on behalf of the Respondent. <br />4. 1 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 />Name: Title: <br />Signature: Date: <br />EH D 22-02-005 Rev 05/07 <br />