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SAN. JOAQUIN Environmental Health Department <br /> —COUNTY <br /> cqr Greatness 9raw- <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 ofthis inspection. This certification form must be submitted to the Environmental Health Department(EHD) address <br /> the bottom 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 orwill be taken for each violation <br /> Copies of sample results/manifestsftraining records/other appropriate paperwork, and/or photos verifying corrections <br /> Operator's certification <br /> Inspection Date: April 25, 2019 Inspected By: CESAR RUVALCABA <br /> Facility Address: 24532 CLOUGH RD, ESCALON CERS ID: 10186233 <br /> I certify under penalty of law that: <br /> 1. I have corrected the violations specified in the Inspection Report from the above-mentioned inspection date. <br /> 2. I have personally examined the following documentation submitted as proof of compliance FOR EACH VIOLATION <br /> I believe the information to be true, accurate, and complete: <br /> Photos Papeiwork Statement <br /> 3. I am authorized to submit this certification on behalf of the Respondent. <br /> 4. I am aware that there are significant penalties for submitting false information, including the possibility of a fine and/ <br /> imprisonment for known violations. (HSC25191) <br /> Name: Title: <br /> Signature: Date: <br /> 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209464-0138 1 www.sjcehd.com <br />