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SAN JOAQU[N Environmental Health Chep-armsni <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 /> at the top of this form within 30 days of mosipt of the Inspection Report. HSC 25404.1,2(c)(1) <br /> All corrections to other vrofatone noted in the attached Inspection Report(IR)or Continuation Form,or disputes to any <br /> violations,are to be submitted using this oerldcation and retumed to EHd %ftin 30 dans Unless otherwise specified in the <br /> Inspection Report. HSC 25185(c)(3) <br /> Note: All END staff time associated with failing to comply by the above noted dates will be <br /> billed at Ow current hourly rate <br /> For this certification to be Complete, the opemlar of the site must Include: <br /> A statement documenting what corrective actions were taken or wtii be taken for each violation <br /> Copies of sample resultslmanifesislhafnirrg mcordslottferappropriate paperwork,and/or photos verifying <br /> comactions <br /> Operator's certification <br /> Inspection Date: December 28,2018 Inspected By: LYDIA BAKER <br /> I;acrlity Address: 7679 LONGE ST,STOCKTON CERS ID: 10184658 <br /> 1 certify under penalty of law that: <br /> 1, I have correcEed 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 compiianoe FOR EACH VIOLATION <br /> and I believe the Information to be true,accurate,and complete: <br /> Photos �t'aperwork u/Statement <br /> 3. 1 am authorised to submit this certification on behalf of the Respondent <br /> 4, 1 am aware that there ars significant penalties for submitting false Information,including the possibility of a fine <br /> andforimprisonmardfarknown violations. (HSC25191) <br /> Name, l-Al ?c f ( �ra!Ajp] Title: Plaqf' lc�t`r3rc°P)a,ne✓ �0.na 7el- <br /> Signature: etcu. -- Date: 141av .7-017 <br /> 1868 E.Hazelton Avenue I Stockton,CaNfornis 952051 T 209 468.34201 F 209 464-0138 1 www.sjnehd,00m <br />