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San Joaquin County <br /> Environmental Health Department <br /> 18138 East Hazelton Avenue, Stockton, California 95205-6232 <br /> Te/epho e: (209)468-3420 Fax:(209)468-3433 Web:www.sjgov.org/ehd <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 form must be submitted to the Environmental Health Department(EHD) address ; <br /> the top of this form within 30 days f 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 t 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/ anifests/training records/other appropriate paperwork, and/or photos verifying corrections <br /> Inspection Date: October 03, 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 violat ons specified in the Inspection Report from the above-mentioned inspection date. <br /> 2. 1 have personally examin d 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 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 and/ <br /> imprisonment for known v olations.. (HSC 25191) <br /> Name: f h Title: SC C <br /> Signature: Date: (�c 11 <br />