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Environmental Health Department <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 ofreceipt of this inspection.This certification form must be submitted to the Environmental Health Department (EHD)address atthe 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 anyviolations, are to be submitted using this certification and returned to EHD within 30 days unless otherwise specified in theInspection Report.HSC 25185(c)(3) <br />Note:All EHD staff time associated with failing to comply by the above noted dates will bebilled at the current hourly rate. <br />For this certification to be complete,the operator of the site must include:·A statement documenting what corrective actions were taken or will be taken for each violation ·Copies of sample results/manifests/training records/other appropriate paperwork, and/or photos verifying corrections·Operator’s certification <br />I certify under penalty of law that: <br />1.I have corrected the violations specified in the Inspection Report from the above-mentioned inspection date. <br />2.I have personally examined the following documentation submitted as proof of compliance FOR EACH VIOLATIONand I believe the information to be true, accurate, and complete: <br />_______Photos _______Paperwork _______Statement <br />3.I am authorized to submit this certification on behalf of the Respondent. <br />4.I am aware that there are significant penalties for submitting false information, including the possibility of a fineand/or imprisonment for known violations. (HSC 25191) <br />Name:_____________________________________Title:________________________________ <br />Signature:__________________________________Date:_______________________________ <br />Inspection Date:Inspected By:June 20,2018 ELENA MANZO <br />Facility Address:CERS ID:1033 W CHARTER WAY, STOCKTON 10181461 <br />1868 E. Hazelton Avenue | Stockton, California 95205 | T 209 468-3420 | F 209 464-0138 | www.sjcehd.com