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_t <br /> SAN ,40AQUIN <br /> a Environmental Health Dertm <br /> paent <br /> — COUNTY- <br /> -- \` Greotness grows here . <br /> RETURN TO COMPLIANCE CERTIFICATION <br /> �. Any MINOR viola tons noted In the 'Notice to Comply' In the attached Inspocllon Report most be corrected within3e tl <br /> ays <br /> receipt of this Inspection. This certification form must be submitted to the Environmental Health Department (EHD) addresst <br /> at the top of this form within 30 days of receipt or the Inspection Report, HSC 25404 .1 .2(c)(1 ) <br /> All Co[rections to th violations noted In the attached Inspection Report (IR) or Continuation Form , of disputes to any <br /> violations, are to be submitted using this certification and returned to EHD within 30 days unless otherwise specified In the Qvi <br /> Inspection Report. HSC 25185(c)(3) \\ <br /> Note: All EHD staff time associated with falling 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/tralning recordslother appropriate paperwork , andfor photos verifying <br /> corrections <br /> Operator's certification <br /> Inspection Date : December 10 , 2018 Inspected By : TRICIA DAI <br /> Facility Address : 221 N WILSON WAY , STOCKTON CERS ID : 10182873 <br /> I certify under penalty of law that: <br /> 1 . 1 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,, / <br /> accurate , and complete: / <br /> `r Photos J Paperwork J 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 / <br /> Name : Jb�lv� QC t5 \-C;) Title : a5% ail d4bila�1 I nsu r e <br /> Signature : Date : Al 0 \� <br /> iM E. Hazelton Avenue I Stockton , California 952051 T 209 468-3420 F 209 464 -0138 wvnv .sjceh <br />