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S n N I O p n U IN <br /> Environmental Health Department <br /> COUNTYIV <br /> Greatness grows 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(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 <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 resuits/manifests/training records/other appropriate paperwork, and/or photos verifying corrections <br /> Operator's certification <br /> Inspection Date: December 05, 2019 Inspected By: GARRETT BACKUS <br /> Facility Address : 1003 HUMPHREYS DR, STOCKTON CERS ID : 10186787 <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 /> C Photos Xpaperwork 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 and/or <br /> Imprisonment for known violations. (HSC 25191 ) <br /> Name: nrV�j 4 V ) A Title: M,4/ 1V�� M 62 , <br /> Signature : .--, � Date: Dig C 3 1 ZO / 9 <br />