Laserfiche WebLink
UN <br />RECEIVED <br />San Joaquin County <br />Environmental Health Department <br />1868 East Hazelton Avenue, Stockton, California 95205-6232 MAR 3 0 2017 <br />Telephone. (209) 468-3420 F". (209) 46&3433 Web: wwwsIgmoW/ehd <br />ENRONMENTAL HEALTH <br />RETURN TO COMPLIANCE CERTIFICATVIIPYPARTM ENT <br />Any MIbjQR violations noted in the "Notice to Comply' in the attached Inspection Report must be corrected within 30 dM of <br />receipt of this inspection. This certification form must be submitted to the Environmental Health Department (EHD) address <br />at the top of this form within 30 days of receipt of the Inspection Report HSC 25404.1.2(cXl) <br />All corrections to other violeflons noted in the attached Inspection Report (IR) or Continuation Form, or disputes to any <br />violations, are to be submitted using this certification and returned to EHD within 30 dans unless otherwise specified in the <br />Inspection Report. HSC 25185(c)(3) <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 complete, the 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 resufts/manifeststtraining records/other appropriate paperwork, and/or photos verifying <br />corrections <br />Operator's certification <br />Inspection Date: July 29, 2015 Inspected By: <br />Fatinah Zareef <br />Facility Address: 2501 JACKSON AVE CERS ID: 10181511 <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 j�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 <br />and/or Imprisonment for known violations. (HSC; 25191) <br />Name: Nc4j',r&&. 5,64aCAA— Title: <br />Signature:1.11"I'L/ (A 4• 1 , r9z ` ate: 3-30- 2-617 <br />