Laserfiche WebLink
� � � U� & �� � Environmental Health Department <br /> ��18 |� �U0U��U �KK� �� ^ <br /> .~. .. .�° .."^~« ~, ` ^ , <br /> . � <br /> TY--- <br /> RETU <br /> RN TO COMPLIANCE CERTIFICATION <br /> Any MINOR violations noted in the"Notice to Comply" in the attached Inspection Report must be corrected within 30 days of <br /> receipt o/this inspection. This certification form must be submitted to the Environmental Health Department(EHD)address <br /> atthe bottom ofthis form within 80days ofreceipt o[the Inspection Report. HSC 25404.1.2(c)(1) <br /> All corrections to other violations noted in the attached Inspection Report(IR)or Continuation Form, or disputes to any <br /> vio|otionm,are tobesubmitted using this certification and returned VoEMD within 30 days unless otherwise specified inthe <br /> Inspection Report. HSC 25185(c)(3) <br /> Nota: All EHD staff time associated with failing to comply by the above noted dates will be <br /> billed atthe current hourly rate. <br /> For this certification to be complete, the operator ofthe 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 recordslother appropriate paperwork, and/or photos verifying corrections <br /> Operator's certification <br /> Inspection Date: May 08 2018 Inspected By: J[>HNALAN|Z <br /> Facility Address: 1505 T|LL|ELEWIS DR, OTOCKTON CERS |0: 10187685 <br /> I certify under penalty of law that: <br /> 1. 1 have corrected the violations specified in the Inspection Report from the above-mentioned inspection date. <br /> 2. 1 have personally examined the following documentation submitted as proof of compliance FOR EACH VIOLATION <br /> and I believe the information to be true, accurate, and complete: <br /> Photos Paperwork Statement <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 possibility of a fine and/or <br /> imprisonment for known violations. (HSC 25191) <br /> Signature? Date: <br /> 1000E. Hazelton Avenue| Stockton, California Q52OS! T 209 468-3420 F 209 464-0138 1 vmww.Nm*hd.vum <br />