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SAN J OAO U I N 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 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/manifestsltraining records/other appropriate paperwork,and/or photos verifying <br /> corrections <br /> Operator's certification <br /> Inspection Date: February 12, 2019 Inspected By: CESAR RUVALCABA <br /> Facility Address: 901 D ARCY PKWY, LATHROP CERS ID: 10184221 <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, ccurate,and complete: <br /> Photos_XPaperwork � Statement <br /> 3. I 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: 75 Lgye o 7- oho j�-S Title: 5tXt,I r-; M MVhUEkf— <br /> Signature- �� Date: �i h S/19 <br /> 1868 E. Hazelton Avenue l Stockton,California 95205 J T 209 468-3420 1 F 209 464-0138 1 www.sjcehd.com <br />