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Jan 03 20 04 : 05p James 2099481693 p . 3 <br /> 01 /03 / 2020 15 : 39 2094683433 SJC EHD UNIT 3 PAGE 02103 <br /> , ANIN Environmental Health Department <br /> SAN <br /> T " i <1 Hi . . <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 Depa" ent (EHO) address of <br /> the bottom of this form within 30 days of receipt of the Inspection Report HSC 25404 , 1 .2(c) ( 1 ) <br /> All cpupctions to other violations noted in the attached Inspection Report ( I R) or Continuation Form , or disputes to any <br /> violations , are to be submitted using this certification and returned to EHD wl1hIn 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 betaken for each violation <br /> Copies of sample results/manifests/training recordslother appropriate paperwork, and/or photos verifying corrections <br /> Operator's certification <br /> Inspection Date : September 26 , 2019 Inspected By : YTRICIA DAI <br /> Facility Address : 3941 N WEST LN , STOCKTON CERS ID : 10182945 <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 . tam aware that there are significant penalties for submitting false information , including the possibility of a fine andk <br /> imprisonment for known violations. ( HSC 25191 ) <br /> Name : _ �: i r � . >L Title: l -1 <br /> i _ t <br /> Signature: - =«��_ Date: <br /> Received Time Jan , 1 2020 4 : 35PM No , 5770 <br />