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I Y <br /> San Joaquin County <br /> Environmental Health Department <br /> 1868 East Hazelton Avenue,Stockton,California 95205-6232 SEP 1 5 2017 <br /> Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.sigov.onglehd <br /> ENVIRONMw -:!`.JT,'-�,L HEALTH <br /> RETURN TO COMPLIANCE CERTIFICATION D`r -P. ENT <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 /> 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 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 falling 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/manifests/training records/other appropriate paperwork,and/or photos verifying <br /> corrections <br /> Inspection Date: August 31, 2017 Inspected By: ELIANNA FLORIDO <br /> Facility Address: 6131 PACIFIC AVE, STOCKTON CERS ID: 10180905 <br /> 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 I believe the information to be true,accurate,and complete: <br /> Photos t/ Paperwork V 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 25191) <br /> Name: ~1 d i/d i b�CC tP� i tz 1iJ Title: vtv i7 E V <br /> Signature:,t' �� Date: �� /C� <br /> {I <br /> I <br />