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0 0S9aoaq n Coun <br /> Environmental Health Department <br /> 1868 East 5205-6 <br /> Hazelton Avenue, Stockton, California 9A <br /> Te/erftne:(209)468-3420 Fax:(209)468-3433 Web:www.sjgov.org/ehd <br /> RETURN TO COMPLIA CE CERTIFIC TIO , <br /> Any MINOR violations noted in the"Notice to Comply"in the attached Inspection Report must be corrected within 30 daRof <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 uts otier�pfise specified in t• <br /> Inspection Report. HSC 25185(c)(3 • • <br /> Note: A[q EHD staff time associated with fa Mng to comply by the above noted dates wall be <br /> *billed at the current hourly rate. <br /> 9 0 00 0 M 0 � <br /> For this certification to be compe e, the operator of the site must include: <br /> A statement documenting what corrective actions were taken or will be taken for each vio aion 0 <br /> Copies of sample results/manifests/training records/other appropriate paperwork, and/or photos verifying <br /> corrections <br /> Operator's certification <br /> C D April 05,2018 nsl pecfed Y:40etty Ho <br /> *ce <br /> iait Address: 830 AUTO PLAZA WAY STE 130 CERS ID: 10187691 <br /> I un er pena y o law that <br /> 1. I hqavbeco•ctea fi*vio a ioT n�cit�d in a nspec ton Repo rom e a ove-men lone inspection ate4W 4D . <br /> 2.01 have personally examined the following documentation submitted a ro of comDha cc F EJC1 <br /> 0 and I believe the information to be true, accurate, and complete: 1�0 0 <br /> otos aperwor Statement <br /> 3. am�a it oriz"ec�to it isceifica i�n 345 11,811 o e gespon en . <br /> 4.,1 am aware that there are significant penalties for submitt�g f se in r•tion, lllc i+th• "lity�� <br /> and/or imprisonment for known violations. (HSC 25191) <br /> ame: Title: <br /> Si nature: D=: <br />