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0 0 S; • .lb�i CoTnt'y <br /> Environmental Health Department <br /> &8.58 East Hazelton Avenue, Stockton, California 9?20P6232 <br /> Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.sigov.org/ehd <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 inspectior*fhis certification form must be submitted to the Environmental Health Department(EHD)addres <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 sp d ' e <br /> Inspection Report. HSC 25185(c)(3) <br /> Note: All EHD staff time associated with failing to comply by the abo�fe Crated dates Will <br /> 0 0 biBGed at the current hdurly rate* <br /> 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 vio a ion M <br /> Copies of sample results/manifests/training records/other appropriate paperwork, and/or photos verifying <br /> correction _ <br /> Operator's certification <br /> Inneectl e: May 30,2018 IIs ac 9j Aaron Hang <br /> F2aciNt Add-Address: 014931 N FLAG CITY BLV CERS ID: 10182237 <br /> I ce i un er pena y o law that: - <br /> 1.eand <br /> vcor ct t viol000 �onsspeci� e�pec ion of from t:a ove-men lone inspection a e. <br /> 2e personally examined the following documentation submitted as roof of compliance FOR EACH VIOLATION <br /> believe the information to be true, accurate, and complete: <br /> - PM Pap tats ement <br /> 3. I•�u ori • tcm�cert fica�on half f t=p�d <br /> 4. I am aware that there are significant penalties four submitting false information including the ossibilit of a fin <br /> Viand/or imprisonment for known violations. (HSC 25191) <br /> Name: Title: <br /> Si nature: Date: <br />