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SANJOARIN Environmental Health Department <br />RETURN TO COMPLIANCE CERTIFICATION <br />Any MINOR violations noted in 6e "Nohoe to Comply' in the 2ttached Inspection Report must be conicW within 30 days of <br />receipt of this inspection This Certification form mist be submitted to the Errvirorrmental Health Department (E HD) address <br />at the top of this farm within 30 days of receipt of the IrmpecbDn Report- HSC 25404 1.2(c)(1) <br />All corrections to other violations noted in the attached Inspection Report {IR} of Continuation Farm- or disputes to any <br />violations, are to he submitted using this certiWtion and retumed to EH 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 co rrective actions were taken or %ill be taken for each violation <br />Copies of sample resultslmanifeststtraining recordslothef appropriate papehworis, andlor photos verdying <br />c oarection s <br />Operator's certification <br />Inspection Date, July 78, 2018 <br />Facility Address, 2017E E GAWINE RD. STOCKTON <br />I certify under penahy of law that: <br />Inspected By: CEAR RiJVALABA <br />CER ID: 10183403 <br />1 I have corrected the violations Specified in the I n5pectio n Report from the 040ve-mentioned inspection date - <br />2. 1 have personally examined the following documentation submitted as proof of compliance FOR EACH VIOLATION <br />and I bgrieve the information to be true. accurate- and oamplete: <br />Photos Paperwork Statement <br />3. 1 am authorized to submit this certficatron 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 />anftr imprisonment for known violations. (HSC 25191) <br />Name: Slit _ w, 5G, Title' JAS -L- e <br />Signature: _ r�.- � Date: <br />'868 E Hazeli'or Aven;Je - Sl cicton, Califorma 952`35 1 T 209 469-3420 i F 20q 4b4-013$ 1 www sjwhd wry <br />