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) OAN Environmental Health Department <br /> SAN 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 at <br /> the bottom 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 failing to comply by the above noted dates will be <br /> billed at the current hourly rate . <br /> i <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 corrections <br /> Operator' s certification <br /> Inspection Date : January 08 , 2020 Inspected By : GARRETT BACKUS <br /> Facility Address : 1025 E PARK ST , STOCKTON CERS ID : 10182431 <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 _ZPaperwork LStatement <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/or <br /> imprisonment for known,�vio`lations , (HSC 25191 ) <br /> LA <br /> Name : Ipk 1 1',l t (4 �� Title : @7yU v' ll <br /> Signature : 4Date :OF <br /> RECEIVED <br /> JAN 2 7 2020 <br /> ENVIRONIII•W1AL IICALTI-I <br /> DE 1'AR" I • � IP. Nrr <br />