Laserfiche WebLink
0 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.siCIov.orq/ehd <br />RETURN TO 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 thiseinspection.- This certification form must be submitted to the <br />Inspection Report. <br />All corrections to other violations noted in the attached Inspection Report (IR) or Continuation orm,or <br />disputes to any violations, are to be submitted using this certification and returned to EHD within 30 days <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 />• Operator's cercation <br />r—T-7-P M 17 M <br />4muffokq�� <br />MZM <br />TITM74M]MV <br />1. 1 have corrected the violations specified in the Inspection Report from the above-mentionerel <br />inspection date. I <br />*- <br />WITM In ED I EVER I Man its] goo F I I Is jamse I - 161111P <br />6- 411 <br />IIIIIIIIIIIII:URGUM [AMAT400 I- . . son* j 1;4 <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 <br />possibility of a fine and/or imprisonment for known violations. (HSC 25191) <br />Name: Title: <br />77= <br />EHD 22-02-005 Rev 10/09 <br />ma <br />