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Jun 1518, 12:21p <br />SAPS JOANIN <br />C N! T , <br />p.3 <br />Environmental Health Department <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 />All corrections to other violations noted in the attached Inspection RI eport (IR) or Continuation Form, or disputes to any <br />violations, are to be submitted using this certification and returrmed t1 EHD within $0 rJays unless otherwise specified in the <br />Inspection Report. HSC 25185(c)(3) <br />Note- All EHD staff time associated with failing to ca reply by the above noted dates will be <br />billed at the current hourly rate. <br />For this certification to be complete, lheope torof the site must include: <br />A statement documenting what corrective actions were to en or will be taken for each violation <br />Copies of sample resultslmanifestsltraining records/other appropriate paperwork, and/or photos verifying <br />corrections <br />Operator's certification <br />Inspection Date: June 13, 2018 Inspected By: <br />JAMIE LIMA <br />�arilifv ArlArccc• SAAF Par.ifir_ Ava .S'trnnktnn I CFRS In- 104119754 <br />certify under penalty of law that <br />1. 1 have corrected the violations specified in the Inspection �eport from the above-mentioned inspection date. <br />2. 1 have personally examined the foliowing 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 oehalf of the Respondent <br />4. 1 am aware that there are significant penalties for submit�ng false information, including the possibility of a fine <br />andlor imprisonment for known violations. (HSC 25191) <br />T <br />Name: ='' %-- Title: <br />Signature: t �✓~rn �.r Date: <br />1868 E. Hazelton Avenue I Stockton, California 95265 1 T 209 468-34201 F 209 464-0138 l www.sjcehd.com <br />