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San Joaquin County <br /> Environmental Health Department <br /> 1868 East Hazelton Avenue, Stockton, California 95205-6232 <br /> Telephone:(209)468-3420 Fax:(209)468-3433 Web:WWW.slQov orcI/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 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 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 <br /> corrections <br /> Inspection Date: October 29, 2018 Inspected By: JOHN ALANIZ <br /> Facility Address: 2201 W WASHINGTON ST, STOCKTON CERS ID: 10186471 <br /> 1 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) 1 1_ <br /> Name: �t�`�'t'1� �r(�.5Y�1,M� Title: �I� p_ <br /> Signature: Date: 1,2- <br /> r <br />