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SHAUN <br />1 C(MNIY <br />RETURN TO COMPLIA <br />Environmental Health Department <br />E CERTIFICATION <br />Any MINOR violations noted in the *Notice to Comply' in the attached Inspidion Report must be corrected within 30 days of <br />receipt of this inspection. This certification form must be submitted to the vironmental Health Department (EHD) address <br />at the top of this form within 30 days of receipt of the Inspection Report. H C 26404.1.2(c)(1) <br />All corrections to other violations noted in the attached Inspection Report (QR) or Continuation Form, or disputes to any <br />violations, are to be submitted using this certification and returned to EHD in unless otherwise specified in the <br />Inspection Report, HSC 25186(c)(3) <br />Note: All EHD staff time associated with failing to comply�y the above noted dates will be <br />billed at the current hourly rate. <br />For this certification to be complete, the operator of flesite must include: <br />A statement documenting what corrective actions were taken or m ill be taken for each violation <br />Copies of sample results/manifests/training records/other appropr ate paperwork, and/or photos verifying <br />corrections <br />Operator's certification <br />Inspection Date: <br />Facility Address: <br />Juiv 09. 2018 <br />901 D ARCY PKWY, LATHROP <br />I certify under penalty of law that: <br />Inspected By: LYDIA BAKER <br />CERS ID: 10184221 <br />1. 1 have corrected the violations specified in the inspection Report forn the above-mentioned inspection date. <br />2. 1 have personally examined the following documentation submitto d as proof of compliance FOR EACH VIOLATION <br />and I believe the information to be true, accurate, and complete: <br />Photos <br />3. 1 am authorized to submit this certification on behalf of the <br />4. 1 am aware that there are significant penalties for submitting <br />and/or imprisonment for known violations. (HSC 25191) <br />Statement <br />information, including the possibility of a fine <br />1868 E. Hazelton Avenue I Stockton, California 952051 T *9 468-34201 F 209 464-0138 1 www.sjcehd.cont <br />