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4.j <br /> SAN J O A Q U I N Environmental Health Department <br /> Y <br /> t' <br /> RETURN TO COMPLIANCE CERTIFICATION <br /> t. <br /> Any MINOR violations noted in the "Notice to Comply" in the attached Inspection Report must be corrected within 30 days of l <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 billed <br /> 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 results/manifests/training records/other appropriate paperwork,and/or photos verifying corrections <br /> Operator's certification <br /> Inspection Date: <br /> FebruarY 25, 2020 Inspected By: PAUL NSO <br /> Facility Address: 2057 S EL DORADO ST, STOCKTON CERS ID: 10181361 <br /> I certify under penalty of law that: <br /> the Inspection Report from the above-mentioned inspection date. <br /> 1. I have corrected the violations specified in <br /> h following ll uea onate and documentation <br /> complete:itted as proof of compliance FOR EACH VIOLATION <br /> 2. 1 have personally examined <br /> and I believe the information <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 possibility of a fine <br /> and/or imprisonment for known violations. (HSC 25191) <br /> Title: <br /> � �,�,�� c�'/�yAr►^Q <br /> Name: <br /> _ A Date: S 1,23 2ZSignature: <br /> - w y <br />