Laserfiche WebLink
Environmental Health Department <br />S Q N 2� D Q U I N <br />--- COUNTY... . <br />odic;,r ; r= .; <br />RETURN TO COMPLIANCE CERTIFICATION <br />Any MINOR violations noted in the "Notice to Comply" in the attached Inspection Report must be corrected within 30 days. of <br />receipt of this inspection. This certification form must be submitted to the Environmental Health Department (EHD) address at <br />the bottom of this form within 30 days of receipt of the 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 disputes to any <br />violations, are to be submitted using this certification and returned to EHD within 30 days 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 complefie, the operator ofihe site must include: <br />A statement <br />documenting what corrective actions were taken or will betaken for each violation <br />Copies of sample results/manifests/training records/other appropriate paperwork, and/or photos verifying corrections <br />Operator's certification <br />Inspection Date: <br />Facility Address: <br />October 11, 2019 Inspected ay: <br />CLAUDIA MURO <br />2545 W HAMMER L.N, STOCKTON CERS ID: 10187831 <br />I certify under penalty of law that: <br />1 have corrected the violations specified in the Inspection Report from the above-mentioned inspection date. <br />2. I 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 />X Photos X Paperwork X Statement <br />3. I am authorized to submit this certification on behalf of the Respondent. <br />4. I 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: Dwain. Bachmann Title: EVS Supervisor , <br />Signature:, <br />Ir-is'r/ 9 <br />