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SAN JOANIN Environmental Health Department <br /> !' elf 1 lu 7 w <br /> RETURN TO COMPLIANCE CERTIFICATION <br /> Any WlblQ$violations noted in the`Notice to Comply'in the attached Inspection Report must be Gold within 3D darn of <br /> receipt of this inspection. This certification form must be submitted to the Environmental Health Department(EHD)address at <br /> the bottom of this form within 30 days of receipt of the Inspection Report. HSC 25404.1.2(c)(1) <br /> All CgMogns to other violatIGGIj 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 devs 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 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 resultslmanifests/trnining recordslother appropriate paperwork,and/or photos verifying corrections <br /> Operator's certification <br /> Inspection Date: Februaj y 19, 2020 Inspected By: ROBERT LOPEZ <br /> Facility Address: 2504 MONTE DIABLO AVE, STOCKTON CERS ID: 10423465 <br /> 1 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 fallowing documentation submitted as proof of compliance FOR EACH VIOLATION <br /> and I believe the information to be true,accurate,and complete: <br /> X Photos_-_Paperwork Statement <br /> 3. 1 am authorized to submit this certification on behalf of the Respondent. <br /> 4. lam aware that there are significant penalties for submitting false information, including the possibility of a fine and/c <br /> Imprisonment for known violations. (HSC 28191) <br /> Name: i21 s -rCs-+r Tide: IE to 5 i/l kA*JA- �-e <br /> Signature: �_�� _ Date: 3 ,�Zo <br />