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SAN JOAHIN Environmental Health Department <br /> RETURN TO COMPLIANCE CERTIFICATION <br /> Any MINOR violations rested in the ' Notice to Comply" in the attached Inspection Report must be corrected within 34 dans of <br /> receipt of this inspaction. This certificatipn form must be submitted to the EnvIronmentai Health Oepartmont (EHD} address <br /> at the top of this farm within 39 days of receipt of Ow Inspection Report. FISC 25404 , 1 .2(0) ( 1 ) <br /> All corrections to other oblations noted in the attached Inspection Report ( IR) or Continuation Form , or disputes to any <br /> violations, are to be submitted using thla caddication and returned to EHf within 39 dans unless clheiruise speo6ed In tho <br /> Inspection Report HSC 251 $5(c)( 3) <br /> Notes 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 saatement documenting what corrective actions ware taken or will be taker: for each violatioat <br /> Copies of sample rasults1manifesta4rainiN records;other appropriate paperworic anctlor photos verifying <br /> corrections <br /> Operator 's certrf,eatlon <br /> Inspection pate; _F taruary 12, 2019 Inspected ay : ROBERT LOPE <br /> Facility Address : 345S MADISON ST, STOCKTON-- - - . . . . +ITERS la. 10182353 <br /> I certify under penalty of law that: <br /> t , 1 have corrected tate violations specified In the Inspection Report from the above-manhwed inspection date , <br /> 2. 1 have personalty examined the following documentation submitted as proof of compliance FOR EACH VIOLATION <br /> and I believe the Infomtation to he true, accurate , and comptete: <br /> Photos Paperwork or� Statement <br /> 3. 1 am authorized to submit this certification on behalf of the Respondent. <br /> 4 , 1 ant aware that More are significant penalties for suhmittincq false information ; including the possibility of a fine <br /> and?or imprisonment for known violations . (HSC 2511 ) <br /> Name: L r� & L4 r. r<, Title: ._ _ <br /> Signature: _ t :. _ Date ; r ` <br /> 1858 I= . HazOton Avenue I Slogkton, California 95205 1 T 249 468 ,3420 1 p 209 464eOl3B I vwww, sjcehd. eom <br />