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San Joaquin County <br />Environmental Health Department <br />1868 East Hazelton Avenue, Stockton, California 95205-6232 <br />Telephone. (209) 468-3420 Fax. (209) 468-3433 Web., www.gdgovoWLe <br />.bd <br />RETURN TO -COMPLIANCE, CERTIfICATION <br />Any MINOR violations noted in the "Notice to Comply" in the attached Inspection Report must be ggrrected within 30 dimLs of <br />receipt of this inspection. This certification form must be submitted to the Environmental Health Department (EHD) address; <br />the top of this form within 30 days of receipt of the Inspection R.eporL HSC 25404.1,1.2(c)(1) i 14 ' " ; <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 dap unless otherwise specified in the <br />Inspection Report. HSC 25185(c)(3) <br />Miff M M. M V M TM i=; = <br />A statement documenting what corrective actions were taken or will be taken for each violation <br />Copies of sarnple results/manifestsftrainitig recordslother appropriate paperwork, and/orlphotos verifying correctio <br />Operator's certification I <br />I I =- MIMI I <br />9MMUL's", a <br />�nspgcted RX: Elena Manzo, <br />Facility AddreSS: 2072, 1 <br />1 certify under penalty of law that: <br />1; MMMMUT <br />1 , .;1 :11 # 17-111 111:1 1 1 <br />2. 1 have personally examined the following documentation submitted as proof of compliance FOR EACH VIOLATION z <br />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. 1 am aware that there are significant penalties for submitting false information, including the possibility of a fine andlo <br />imprisonm r known violations. (HSC; 25191) <br />o <br />Nam jitle: P <br />�-7 <br />E <br />