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18 2018 14: 35 HP Fax <br /> page 1 <br /> M% <br /> SAN ._ 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 of <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 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 operatorof 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 <br /> corrections <br /> Operator's certification <br /> Inspection Date : December 11 , 2018 Inspected By : ZUNA BARKER <br /> Facility Address : 140 E LATHROP RD , LATHROP CERS ID : 10182153 <br /> 11 1 WWII <br /> 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 . 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 Paperwork 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 ) <br /> p I <br /> Name : J � ) y2`_ � f ytlo "/ Title : /, ty' /'I ePAoe� <br /> Signature : <br /> A <br /> d 2018 <br /> NVIRONMEHTAL HEALTH <br /> ' r7PMIT/SER VICES <br /> 1888 E . Hazelton Avenue I Stockton , California 952061 7 209 468-3420 1 F 209464-0138 i www . sjcehd .com <br /> Received Time Dec , 20 , 2018 111OPM No . 4501 <br />