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SAN J OAQ U I N Environmental Health Department <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 rete pt of the Inspection Report MSC 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 specifed 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 act ons were taken or will be taken for each violation <br /> Copies of sample resultslmanitests/training recordslother appropriate paperwork and/or photos verifying corrections <br /> Operators certification <br /> Inspection Date: July 25, 2019 Inspected By: TRICIA DAI <br /> Facility Address: 2141 E ANDERSON ST. STOCKTON CERS ID: 10181955 <br /> 1 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 subm.tted 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 informat•on includ.ng the possibil ty of a fine <br /> and/or imprisonment for known violations (HSC 25191) <br /> Name: Title: <br /> Signature: Date: <br /> 1868 E HaZe.ton Avenue- Stockton California 95205 T 209468-34201 F 20946-4-0133 I %,PV:v.Slcehd com <br />