Laserfiche WebLink
r <br /> S ,,3oAQt)1KCQUNTYa <br /> ENVIRO MENTAL:HEALTH:DEPARTMENT"` <br /> 600 East Main Street,-Stockton,CA 95202-3029 <br /> Telephone:(209)468-3420 Fax:(209)468-3433 Web:wm s' ov.oralehd <br /> TO COMPLIANCECERTIFICATION <br /> Any MINOR violations noted in,the_"Notice to Comply- in the attached Inspection Report must be- <br /> co <br /> e- <br /> correCied within'30 days`of.receipt of ti isInspection-��This certificationaform must be,submitted to the <br /> Environmental Health..Department(EHD),address at the top of this form within"30 days.of receipt of the <br /> Irfspection`Report <br /> Ail co ctrons to other violations noted in the attached Inspection-,Report(IR) of'Continuation Form, or <br /> disputes to any yiolafions, are to'be submitted using this certification and:returried to EHD'within�30 days <br /> unless othennrise specifediin e Inspection'Report. <br /> Note . AIL.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 t0 be com l@teAhe'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.results7manifests/training records/other,appropriate paperwork and/or photos <br /> verifying corrections <br /> • o rator's certification <br /> Inspection Date: -7 -10- 6,2 Inspected By: <br /> C:A C r4�p• <br /> Facility,Address: /7 ZV i 1-� 46 <br /> EPA I ; J. 06C)6gf c/ <br /> A440, <br /> ' <br /> C { <br /> certify vrider penalty of law that:' <br /> 1. 1 have corrected the violations specked in the Inspection Report from the above-mentioned <br /> inspection date. <br /> 2. 1 have personally.examined the following documentation submitted as proof of compliance FOR <br /> EAC'HiMb1ATION and I believe the information to'be'true, accurate, and complete: <br /> x <br /> Photos °r V" Paperwork &10 Statement <br /> 3. 1 am authorized-to submit-this certificatio' 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 /> e <br /> Name: Title: A i2 zva, <br /> a <br /> Signature: - Date: <br /> eun nn nn nne o....noma <br />