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San Joaquin County RECEIVE® <br /> Environmental Health Department <br /> 1868 East Hazelton Avenue, Stockton, California 95205-6232 <br /> Telephone: (209)468-3420 Fax:(209)468-3433 Web:vmw.s*a v.org/el{� P 2 4 2018 <br /> RET RN TO COMPLIANCE CERTIFICATMMENTALHEALTH <br /> /SERVIAny MINOR violations noted in th "Notice to Comply" in the attached Inspection Report must be corrected within 30 days of <br /> receipt of this inspection. This c rtification form must be submitted to the Environmental Health Department(EHD) address <br /> the top of this form within 30 day of receipt of the Inspection Report, HSC 25404.1.2(c)(1) <br /> All corrections to other violations rioted in the attached Inspection Report (IR) or Continuation Form, or disputes to any <br /> violations, are to be submitted us ng this certification and returned to EHD within 30 days unless otherwise specified in the <br /> Inspection Report. HSC 25185( (3) <br /> Note: All EHD staff ti a associated with failing to comply by the above noted dates will be <br /> billed at the curren hourly rate. <br /> For this certification o be complete, the operator of the site must include: <br /> A statement documentin what corrective actions were taken or will be taken for each violation <br /> Copies of sample result /manifests/training records/other appropriate paperwork, and/or photos verifying corrections <br /> Inspection Date: Augusl 29, 2018 inspected By: STACY RIVERA <br /> Facility Address: 440W DR MARTIN LUTHER KING JR BLVD CERS ID: 10180903 <br /> 1 certify under penalty of law that <br /> 1. I have corrected the viol tions specified in the Inspection Report from the above-mentioned inspection date. <br /> 2. 1 have personally exami ed the following documentation submitted as proof of compliance FOR EACH VIOLATION <br /> I believe the information to be true, accurate, and complete: <br /> Photos Paperwork Statement <br /> 3. 1 am authorized to sub it this certification on behalf of the Respondent. <br /> 4. 1 am aware that there a e significant penalties for submitting false information, including the possibility of a fine and/ <br /> imprisonment for known violations. (H C 25191) <br /> Name: IC % Title: <br /> Signature: Date:ck" uO" �e-� <br /> 1 <br /> as �� ae jo, 4 <br /> 2 f6,-6 <br /> (ev�%' 60 <br /> II �� q <br /> Ld 31�,- �- �ve� rl�9h�d <br />