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;,�ti the N 1 U f N Environmental Health Department <br />C' 0 U I',I T Y. <br />���:.�u�,py111'•� {J 1'f,%(Ifl'l l'SS (f i'tJ Nr3 it 6'i $. <br />NVIRONMENTAL HE <br />RETURN TO COMPLIANCE CERTIFICATION DEPARTMENT <br />Any MIROR violations noted in the "Notice to Comply" In the attached Inapectlon Report must be aorregWd within 30 days of <br />receipt of this inspection. This eertifloation form must be submitted to the Environmental Health Department (EHD) address I <br />the bottom of this form within 30 days of receipt of the Inspection Report. HSC 25404.1.2(c)(1) <br />All oorrectiens to other vlolatlona noted in the attached Inspection Report (IR) or Continuation Form, or disputes to any <br />violations, are to be submitted using thle certification and returned to EHD within 30 days. unless otherwise specified In the <br />Inspection Report. HSC 261B6(c)(3) <br />Note: All EHD staff time associated with failing to comply by the above noted dates will be <br />billed at the current hourly rate. <br />For this certification to be complete, the operator of the site must Include: <br />A statement documenting what corrective aciions were taken or will be taken for each violation <br />Copies of sample resultslmanlfesteltr°aining recordslother appropriate paperwork, and/or photos verifying corrections <br />Operator's Certification <br />Inspection Date: June 04, 2019 Inspected By: SHEWITWaLDEAREGAI <br />Facility Address: 1580 W MAIN ST, RIPON CER.S ID: 1 10180640 <br />I certify under penalty of law that: <br />1, 1 have corrected the violations specified in the Inspection Report from the above-mentloned inspection date, <br />2. [have personally examined the following documentation submitted as proof of compliance FOR EACH VIOLATION <br />I believe the Information to be true, accurate, and complete: <br />Photos _ Paperwork Statement <br />$. I am authorized to submlt this certification on behalf of the Respondent. <br />1. I am aware that there are significant penalties for submitting false information, Including the possibility of a fine and <br />Imprisonment for known violations. (HSC 26101) 1A <br />Name, /U d 'Title: (-jv (UNI W %VLC_ie, <br />Signature:`--- _-- bate: 221:7 -Vi 9 <br />1868 F, Hazelton Avenue I Stockton, California 96205 1 T 209 468-3420 1 F 209 484-0138 1 www.sjcelid.com <br />