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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 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 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 />·Operator’s certification <br />I certify under penalty of law that: <br />1.I 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 />_______Photos _______Paperwork _______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:_____________________________________Title:________________________________ <br />Signature:__________________________________Date: _______________________________ <br />Inspection Date:Inspected By:January 10, 2018 MARIBEL FLOHRSCHUTZ <br />Facility Address:CERS ID:6518 PACIFIC AVE, STOCKTON 10180931 <br />1868 E. Hazelton Avenue | Stockton, California 95205 | T 209 468-3420 | F 209 464-0138 | www.sjcehd.com