COMPLIANCE INFO_1998-2009 - Laserfiche WebLink

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I FROM FAX NO. :2093699162 c. 02 2009 10:17AM P4 SAN JOAQUIN COUNTY - ENVIRONMENTAL HEALTH DEPARTMENT 600 East Main Street, Stockton, CA 96202-3029 Teiephone.* (209) 468-3420 Fax.- (269) 468-3433 Web; mmwsjgoy.qr_cIiehd ! ZI =11 It I 10 Z, a IN-yelely, W* 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. 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 Inspection Report. 1 46 0 11 6 _16 , For this certification to be complete the operator of the site must include. • A statement documenting what corrective actions were taken or will - be taken for each Violation • Copies of sam'ple results/manifests/training records/other appropriate paperwork, and/or photos verifying corrections • Operator's certification 10gam Facility Address: I certify under penalty of law that Inspected By: 1. I have corrected the violations specified in the Inspection Report from the above-mentionO,d inspection date.. 2. 1 have personally examined the folloWng documentation submitted as proof of compliance FOR EACH VIOLATION and I believe the information to be true, accurate, and complete:: Photos ___.;_�Paperworlk Statement 3. lam authofized to submit this certification on behaff of the Respondent. 4. 1 am aware that there are significant penalties for s ubmitting false inforrnation, including the 91) possibility of a fine and/or imprisonment for known violations. (HSC 251 Name: Title: EHD 2?A2-00 ROV 06M loollml=