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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.siaov. ora/ehd <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 <br />at the top of this form within 30 days of receipt of the Inspection Report. HSC 25404.1.2(c)(1) <br />Al! corrections to other violations noted in the attached Inspection Report (IR) or Continuation Formor disputes to any <br />vio at.ons, are :o be submitted using this certification and returned to EHD within 30 days unless otherwise specified in the <br />lnsoection 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 verifying <br />corrections <br />Inspection Date: May 30, 2017 Inspected By: <br />Facility Address: 1351 DUPONT CT, MANTECA CERS ID <br />I certify under penalty of law that: <br />HAZA SAEED <br />185191 <br />1. I have corrected the violations specified in the Inspection Report from the above-mentioned inspection date. <br />2. 1 hese 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 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: d Title: W')L iLls?tiz <br />Signature: l/ Date: <br />Date Reed <br />JUN 0 5 7017 <br />TAX DEPT. <br />