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SAN 1 O A O U I N Environmental Health Department <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(c ) ( 1 ) <br /> All corrections to othel 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 /> 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 appropriale paperwork , and/or photos verifying corrections <br /> Operator's certification <br /> Inspection Date : October 25 , 2019 Inspected By : TRICIA DAI <br /> Facility Address , 1754 E MARIPOSA RD , STOCKTON CERS We 10182935 <br /> I 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 Lpaperwork Statement <br /> 3 , 1 am authorized to submit this certification on behalf of the Respondent . <br /> 46 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 /> Name : bA Imc=(2011 Title : P-na c* III #qtjA�6ER� <br /> Signature : �/j1`�( LQ ( � � Date : � � � � <br />