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f <br /> SAN J O A Q U I N RECEIVE environmental Health Department <br /> - COUNTY - ---- PR 12 2011 <br /> IIONi1�lf I 1 •,. <br /> RETURN TO COMPL� 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 <br /> at 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 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 results/manifests/training records/other appropriate paperwork , and/or photos verifying <br /> corrections <br /> Operator' s certification <br /> Inspection Date : March 08 , 2019 Inspected By : TRICIA DAI <br /> Facility Address : 1634 E CHANNEL ST , STOCKTON CERS ID : 10183871 <br /> I certify under penalty of law that: <br /> V/1 * I 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 /> 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 <br /> and/or imprisonment for known violations . (HSC 25191 ) <br /> Name : + �— ` Title : `�`y`d`j� <br /> Signature : \ Date :It <br /> �i 01 �. ` Z �a J � b 1 wd-�ti n CvNcftNN %41e ✓� G � v► � ,r, e C_c� arc Awd I &rlS(e'c �e <br /> � r„\We1. ft: re1 � dvrNY\ qtt% 'k� mom VSiA � n <br /> cl�� Corr ¢ct �s p,J <br /> ` <br /> 1868 E . Hazelton Avenue I Stockton , California 95205 T 209 468-3420 1 F 209 464- 0138 1 www. sjcehd . com <br />