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= FSSHAW <br /> I Environmental Health Department <br /> r � <br /> =e v 1. a�/ -Greorneis c rows here , <br /> 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(0)(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( 0)(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 : December 03 , 2019 inspected By; JOHN ALANIZ <br /> WE <br /> Facility Address : 4911 BUCKLEY COVE WAY, STOCKTON CERS We 10180983 <br /> certify under penalty of law that, <br /> 1 . I 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 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 viol ns . (HSC 25191 ) <br /> Name Titlelf <br /> Signature: Date : """ <br /> 9 a5ed 9896LLtr6M euueW sPPel WdE-V80 OOOZ 0 uef <br />