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MENNEN <br /> Environmental Health Department <br /> SAN <br /> � �IOAQUIN <br /> COUNTY <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 <br /> ihed Inspection and returnedRo EHD w thin 30 days ueport ( IR ) or l � less herwisedisputes <br /> spec f ednn the <br /> violations , are to be submitted using this certification <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 /> Inspection Date : May 02 , 2018 Inspected By : ROBERT LOPEZ <br /> s : 1002 N BROADWAY AVE , STOCKTON CERS ID : 10183275 <br /> Facility Addres <br /> I certify under penalty of law that: <br /> 1 . 1 have corrected the violations specified in the Inspection Report from the above- mentioned inspection date . <br /> 2 . 1 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 . 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 know Iations . ( HSC 25191 ) <br /> Name : ' S Title : <br /> Signature : Date: <br /> � n�I g: tzog � rM � LA el l � N PV� G t - A-+� L5 J ,P.A41 � <br /> � 1 � � � i. Al, o ►.a (� <J � `� ►t��rllG.a �- . �� J � ia >L� (. ( �T'. <br /> y � y <br /> 1868 E . Hazelton Avenue Stockton , California 95205 T 209 468 -3420 1 F 209 464 -0138 1 www . sjcehd . com <br />