COMPLIANCE INFO_2010-2014 - Laserfiche WebLink

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'0 SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT RECEIVED 600 East Main Street, Stockton, CA 95202-3029 Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.siaov.ora/ehd MAR 16 2012 ENVIRONMENTAL HEALTH RETURN TO COMPLIANCE CERTIFICATION PERMIT/SERVICES Any MINOR violations noted in the "Notice to Comply" in the attached Inspection Report must be corrected within 30 days of receipt of this inspection. This certification form must be submitted to the Environmental Health Department (EHD) address at the top of this form within 30 days of receipt of the Inspection Report. HSC 25404.1.2(c)(1) All corrections to other violations noted in the attached Inspection Report (IR) or Continuation Form, or disputes to any violations, are to be submitted using this certification and returned to EHD within 30 days unless otherwise specified in the Insjpection Report. HSC 25185(c)(3) Note: All EHD staff time associated with failing to comply by the above noted dates will be billed at the current hourlrate. For this certification tobecompletethe operator of the site must include: • A statement documenting what corrective ac ions were taken or will be taken for each violation • Copies of sample results/manifests/training records/other appropriate paperwork, and/or photos verifying corrections mspection Date: rjrr'T=_4 I Facility Address:/ 0 Xb 2 7-Z-:-&/CEPA lD#: 16-7s - C 1 certify under penalty of law that: 1 - I have corrected the violations specified in the Inspection Report from the above-mentioneJ0' inspection date. WU071 A file .1 M 9041 m WA I*] W-11 11010 F-TiTs I 1'sq.7 M M- I I i I I al i a i R I I ril i a cal REA I i I rEW. Ttsi I I rt I r -Art I i is IsTel i a I * I NA t - Photos X Paperwork Statement 4. 1 am aware that there are significant penalties for submitting false information, including the possibility of a fine and/or imprisonment for known violations. (HSC 25191) Name: —Title: 'j, - Signature: 61� Date: -3 EHD 22-02-005 Rev 09/11