Laserfiche WebLink
,?.013-02-22 14:46 Manteca 2099821205 >> <br />SAN JOAQUIN COUNTY FEB 2 2 2013 <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />1868 East Hazelton Avenue, Stockton, California 95205-.8232 SAN JOAQUIN COUNTy <br />Telephone; (209) 468-3420 Fax., (209) ,r wwwAgov,orWehd. ENVIRONMENTAL <br />HEALTH DEPARTMENT <br />Any MINOR violations noted in the "Notice to Comply" in the attached Inspection Report must be <br />goEgoted Within 30 days of receipt of this inspection. This certification form 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 />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 <br />disputes to any violations, are to be submitted using this certification and returned to EHD within 80 days <br />unless otherwise specified in the 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 results/manifests/training records/other appropriate paperwork, and/or photos <br />verifying corrections <br />• Operator's certification <br />Inspection Date: Inspected <br />Facility Address: a?h �- Fftv.� CAMP EPA II)#Q&aL.3 <br />M cA ( CA� q.533 <br />I certify under penalty of law that; <br />1. I have corrected the violations specified 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 />EACH VIOLATION 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 <br />possibilitt n <br />,y �f a fine and/or imprisonment for known violations. (HSC 25191) <br />Name: <br />nature: <br />F.HD 22.02-906 Rev 04!19/12 <br />Title: e <br />#77Z3 <br />