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,F SANa Q Q Environmental Health Department <br /> 4 <br /> p •zl'V COUNTY- <br /> Qf09'S her <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 /> 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 specked 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 corrections <br /> Operator's certification <br /> Inspection Date: September 24, 2018 Inspected By: ROBERT LOPEZ <br /> Facility Address: 603 SAN JUAN AVE, STOCKTON CERS ID: 10486969 <br /> 1 certify under penalty of law that: <br /> 1. 1 have corrected the violations specked 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�aperwork v 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) nn <br /> Name: p iQ/�i� GJ/i-So N Title: U 1,tee for o ree e('!4 <br /> Signature: /'� f� — Date: `4�/� <br /> RECEIVED <br /> OCT 15 2013 <br /> ENVIRONNIFXI'All, 1G;�LTH <br /> DEPARTNIEN'F <br /> 1868 E. Hazelton Avenue Stockton, California 95205 T 209 468-3420 1 F 209 464-0138 1 www.sjcehd.com <br />