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S Q N J O A Q U I N Environmental Health Department <br /> ♦ T�: <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 3C 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 /> Operators certification <br /> Inspection Date: December 13, 2018 Inspected By: LYDIA BAKER <br /> Facility Address: 4606 McCuen Ave. Stockton CERS ID: 10186935 <br /> 1 certify under penalty of law than <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 X 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 /> Name: Kimberly A. Wright Title Director of Risk Management <br /> Signature: LX J 0Date: January 9, 2019 <br /> 1868 E. Hazelton Avenue I Stockton, Califomia 952051 T 209 468-34201 F 209 464-0138 1 www.sjcehd.com <br />