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i <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1868 East Hazelton Avenue, Stockton , California 95206-6232 <br /> Telephone: (209) 468-3420 Fax: (209) 468-3433 Weft; www. s' ov-or /ehd <br /> i <br /> RETURN TO COMPLIANCE CERTIFICATION <br /> Any MINOR violations noted in the " Notice to Comply" in the attached Inspection Report must be <br /> corrected within 30 days of receipt of this inspection . This certification farm must be submitted to the <br /> Environmental Health Department (WD ) address at the top of this form within 30 days of receipt of the <br /> Inspection Report . HSC 25404 . 1 . 2 (c ) ( 1 ) <br /> i <br /> All corrections to other violations noted in the attached Inspection Report ( IR) or Continuation Farm , or <br /> disputes to any violations , are to be submitted using this certification and returned to EHD within 30 days <br /> unless otherwise specified in the Inspection Report. HSG 25185 (c)(3 ) <br /> i <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 /> i <br /> For this C+ rtI ICc tion t0 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 <br /> verifying corrections <br /> • Operator's certification <br /> i <br /> Inspection Date : May 14 , 2019 Inspected By: Lydia Baker <br /> Facility Address : 4469 ESCALQN QEL_ LrOTA EPA ID# : CAL000381886 <br /> I certify under penalty of law that: <br /> 1 . 1 have corrected the violations specified in the Inspection Report from the aboye-, `edt an �� <br /> inspection date . d .; '�_ LJ <br /> i <br /> i u 2 'b 7n9g <br /> 2 . I have personally examined the following documentation submitted as proof of compliance i"QR <br /> EACH VIOLATION and I believe the information to be true , accurate , and complete : <br /> ii) NMEIVIAI~ <br /> l Photos _ Paperwork _. statement Al H PDA �TnR r� <br /> i <br /> 3 . I am authorized to submit this certification on behalf of the Respondent . <br /> 4 - <br /> 1 am aware that there are significant penalties for submitting false information , including the <br /> possibility of a fine and/or imprisonment for known violations . (HSC 25191 ) <br /> i <br /> Name : Title : � � - a�) 1J P <br /> i i ' <br /> Signature : _ <br /> j Date : <br /> i <br /> EHD 22-OMOS Rev 04/19/12 <br /> i <br /> 1. 00 / 1, 00 ' d Copp ## 51 31OHI3 69Z998860Z W61- B1, 0Zf97J190 <br />