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San Joaquin County <br /> Environmental Health Department <br /> 1868 East Hazelton Avenue,Stockton, California 96205-6232 <br /> Telephone. (209)468-3420 Fax:(209)468-3433 Web: LqhA <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 Oays 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 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 m9hb-19dais 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 at corrective actions were taken or will be taken for each violation <br /> Copies of sample resufts/manifeststtraining records/other appropriate paperwork, and/or photos verifying corrections <br /> Inspection Date: May 23, 2018 Inspected By: STACY FIVERA <br /> Facility Address: 1532 N Broadway Ave, Stockton CERS, ID: 10156057 <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 /> I believe the information to be true,accurate,and complete: <br /> Photos Zpaperwork 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/ <br /> imprisonment for known violations. (HSC 25191) <br /> Name: Title: <br /> D <br /> Signature: -Date: <br /> Kew's <br /> Of N �WVOO VC12-0A- 0 e� -Q-0 11 S�F-C�I- <br /> Qr <br />