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Environmental Health Department <br /> SAN 10AHIN <br /> RETURN TO COMPLIANCE CERTIFICATION <br /> Any MINQR violations noted in the"Notice to Comply" in the attached Inspection Report must be corrected within 3Q da 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 pthpr 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 dan unless otherwise specified in the <br /> Inspection Report_ HSC 25185(c)(3) <br /> Note: All EHD staff time associated with tailing 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: Inspected By. <br /> Facility Address: CERS ID: <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 1 believe the information to be true, accurate, and complete: <br /> Photos Paperwork )�, Statement <br /> 3. 1 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 2599'1) <br /> Name: SElr1P M09'GA.1 Title: AAA(SE2 <br /> QSignature: Date: Tud Z�� �d1� -- <br /> 1868 E. € azelton Avenue I Stockton, California 95205 T 209 468-3420 F 209 464-0138 1 www.sjcehci.com <br />