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r <br /> San Joaquin County <br /> Environmental Health Department <br /> La1868 East Hazelton Avenue, Stockton, California 95205-6232 <br /> ' relephone. (209) 468-3420 Fax: (209) 468-3433 Web:www.s ov.or lehd <br /> RETURN TO COMPLIANCE CERTIFICATION <br /> Any MINOR violations noted in the "Notice to Comply" in the attached inspection Report must be corrected within 3a days <br /> receipt of this inspection. This certification form must be submitted to the Environmental Health Department (EHD) addre. <br /> at the top of this form within 30 days of receipt of the Inspection Report. HSC 25404A.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 dans 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 takneach <br /> violation <br /> Copies of sample results/manifests/training recordslother appropriate paperwork, <br /> ap verifYtr <br /> g <br /> corrections <br /> Operator's certification <br /> inspection Date: November 22, 2019 Inspected By: Lydia Baker <br /> Facility Address: 4221 E MARIPOSA RD BLDG D CERS ID: 10585533 <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 following documentation submitted as proof of compliance FOR EACH VIOLA, <br /> and I believe the information to be true, accurate, and complete:UIX <br /> V Photos Paperwork Vr 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 fin <br /> and/or imprisonment for known violations. (HSC 25191) <br /> Name: 4 �}'J Title: <br /> z Date. /2,0 <br /> Signature: <br />