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��c 051710:17a _ p.1 <br /> %M — — - - - - <br /> . . RECEIVED <br /> :' SAN J Q A Q U DEC0 5 2011 Environmental Health Department <br /> . _ <br /> ENVIRONMENTAL HEALTH <br /> PERMIT/SERVICES �✓ <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 farm must be submitted to the Environmental Health Department(EHD) address <br /> 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 retumed 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/manifests/training records/other appropriate paperwork, and/or photos verifying corrections <br /> Operator's certification <br /> Inspection Date: November 07, 2017 Inspected By: CESAR RUVALCABA <br /> Facility Address: 8115S ELDORADO ST, FRENCH CAMP CERS ID: 10180529 <br /> I certify unde7corrected <br /> hat: <br /> �x <br /> 1. I haviolations specified in the Inspection Report from the above-mentioned inspection date. <br /> 2. I hayamined 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 Statement <br /> 3. l 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: Title: <br /> Signature: Date: <br /> 3c], <br /> _ goSa31 '7F AOOOO I IO <br /> 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 466-.­ia?n i r= Ana pan ni,)Q i ....... _:_ , -- .. <br />