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SAN .JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1868 East Hazelton Avenue, Stockton, California 95205-6232 <br /> Tele hone:(209)468-3420 Fax: (209)468-3433 Web:www.smqov.org/ehd <br /> REURN TO COMPLIANCE CERTIFICATION <br /> Any MINOR violations noIted in the "Notice to Comply" in the attached Inspection Report must be <br /> corrected within 30 da of receipt of this inspection. This certification form must be submitted to the <br /> Environrnental Health D partment (EHD) address at the top of this form within 30 days of receipt of the <br /> Inspection Report. HS 25404.1.2(c)(1) <br /> All corrections to other v olations noted in the attached Inspection Report(IR) or Continuation Form, or <br /> disputes to any violation are to be submitted using this certification and returned to EHD within 30 days <br /> unless otherwise spec 1 d in the Inspection Report. HSC 25185(c)(3) <br /> Note: All EHD staff ti a associated with failing to comply by the above noted dates will be <br /> billed at the current hourly rate. <br /> For this certific tion to be complete the operator of the site must include: <br /> • A statement docum nting what corrective actions were taken or will be taken for each violation <br /> • Copies of sample r ults/manifests/training records/other appropriate paperwork, and/or photos <br /> verifying corrections <br /> • Operator's certificati n <br /> Inspection Date: 09/29/2017 Inspected By:Betty Ho <br /> Facility Address: 833 E Eighth St,StocktonCA EPA ID#: CAD982030207 ` <br /> AN 18 2018 <br /> 1 certify under penalt of law that: <br /> 1. 1 have corrected t e violations specified in the Inspection Report from the a boob-mentioned!+AL H -ALTH <br /> inspection date. — , " ,I date. , <br /> 2. 1 have personally xamined the following documentation submitted as proof of compliance FOR <br /> EACH VIOLATIO and 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 <br /> possibility f a fin and/or imprisonment for known violations. (HSC 25191) <br /> Name: QK,QVo eve",Pt Title: &Vr -OLAIZJ(114 fteV UJS <br /> Signature: Date: o1118118 <br /> EHD 22-02-005 Rev 04/19/12 <br />