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San Joaquin County <br /> Environmental Health Department <br /> 1868 East Hazelton Avenue, Stockton,California 95205-6232 <br /> Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.s' ov.o / hd <br /> RETURN TO COMPLIANCE CERTIFICATI N <br /> Any MINOR violations noted in the"Notice to Comply"in the attached Inspection Report must be corre ed withi 30 da s of <br /> receipt of this inspection. This certification form must be submitted to the Environmental Health Depart ent(EH )address <br /> at the top 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 isputes any <br /> violations,are to be submitted using this certification and returned to EHD within 30 days unless otherw a sped ed in the <br /> Inspection Report. HSC 25185(c)(3) <br /> Note: All EHD staff time associated with failing to comply by the above noted dat s will e <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 msuhs/manifests/training records/other appropriate paperwork,and/or photo verifyin <br /> corrections <br /> Inspection Date: October 31, 2017 Inspected By: H 4ZA S EED <br /> Facility Address: 251 D ARCY PKWY, LATHROP CERS ID: 10184 17 <br /> 1 certify under penalty of law that: <br /> 1. I have corrected the violations specified in the Inspection Report from the above-mentioned inspection d 3te. <br /> 2. 1 have personally examined the following documentation submitted as proof of compliance FOR EACH 11OLATION <br /> and I believe the information to be true,accurate, and complete: <br /> Photos Paperwork X 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 po sibility I a fine <br /> and/or imprisonment for known violations. (HSC 25191) <br /> Name: 6fA(1r `of5%/yhe, Title: /Mut14G(' O� P I n <br /> Signature:z —��7 ✓: , fit Date: 141117 <br />