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i <br /> SAN a QA Q U I N Environmental Health Department <br /> RETURN TO COMPLIANCE CERTIFICATION <br /> Any MINOR violations noted in the ` Notice to Comply ' In tM attached Inspection Report must be corrected wilhin 30 rtays •of <br /> reue t of this inspection , This certification form must be submitted to this environmental Health Department ( FHO) address <br /> the top of this farm within 30 days of receipt of the Inspection Report. HSC 25404 . 1 .2 (c)( 1 ) <br /> All corrections to athor yh2latioala noted In the attached Inspection Report ( IR) or Continuation Form , or disputes to any <br /> viot;itions, are to be submitted using this cartiflcation and returned to FHO withinw�thin 30�Iays�ta m unless otbeRvise specified in the <br /> inspection Repast, HSC 25185f�c) (3 ) <br /> Note . All EMD staff time associated with failing to comply by the above noted states 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 staternent documenting what corrective actions were taken or wilt be taken for each vlofation <br /> Copies of sample resultsimanifestattraining record3lother appropriate paperwork , andior photos verifying corfectidns <br /> Operator's cedificatlon <br /> Inspection Date: February 12 2019 inspected By: ROB RT LOPZZ <br /> Facility Address ; 123W SONORA ST, STOCKTON CERS ID. 10184223 <br /> I certify under penalty of taw that: <br /> 1 , 1 have corrected the violations specified in the Inspection Report from the abovewmentioned inspection date, <br /> 2 , I have personal y examInad the foll(hving documentation submitted as proof of ournpliance FOR EACH VIOLATION <br /> and I behave the Informatirrn to be true , accurate , and compfetw. <br /> Photos —+ _ Paperwork. v1 Statement <br /> 3, 1 am authorized to submit this certification on behalf of the Respondent. <br /> 4. 1 am aware that there are signifc cant r enatties for submitting false information , including the possibility of a fine <br /> and/w imprisonment for known violations, (HSC 25191 ) <br /> Nalene; - <br /> - - - ,�' Tale: irc � F j i�z ' Matr gger" <br /> Signature. CW4 _ 4 sate: _ ) q <br /> M5 E . Hazelton Avenue j Stockton . California 952051 T 209468-34201 F 209 4640138 1 Y*ww, sicehd, co+ <br />