Laserfiche WebLink
SAN JOQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />600 East Main Street, Stockton, CA 95202-3029 <br />Telephone: (209) 468-3420 Fax. (209) 468-3433 Iffieb:)6�.s'•�ov.o[g/ehd <br />IN-MIKIR 0 0 <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 ft-� <br />Inspection Report. <br />11 1111, 11111111111 11111�1111 0 1 - 4 * I I <br />o1splies fu Wfj-rT1TrdLF*1 <br />unless otherwise specified in the Inspection Report. <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 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 />Operators certcation <br />Inspection Date: inspected By: <br />Facility Address: 1-44 V' Rvk EPA 1D#: <br />I have corrected the violations specified in the Inspection Report from the above-mentionei <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 _____Paperwork Statemenli <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 thaw <br />possibility of a fine and/or i.'sonment for known violations. (HSC 25191) <br />Name: I'llec,01- <br />a <br />EHD 22-02-005 Rev 10/09 <br />