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i <br /> Environmental Health Department <br /> AM JOUMIN <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 /> t be submitted to the Environmental H alth Department (EHD) address at <br /> receipt of this inspection . This certification form mus <br /> the bottom 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 Continuati n Form , or disputes to any <br /> violations , are to be submitted using this certification and returned to EHD within 30 days Ness 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 incl de : <br /> A statement documenting what corrective actions were taken or will betaken for ach violation <br /> Copies of sample results/manifests/training records/other appropriate paperwork, and/or photos verifying corrections <br /> Operator's certification <br /> Inspection Date : July 22 , 2019 Inspected By : GARRETI BACKUS <br /> Facility Address : 540 N GRANT ST , STOCKTON CERS ID : 10185003 <br /> III= III NEW I HIM MAIN= I NINE= 11 1 MEMO 11 liiiiiiiiiiiiii I IN= I liiiiiii I <br /> I certify under penalty of law that: <br /> 1 . 1 have corrected the violations specified in the Inspection Report from the abov -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 , ncluding the possibility of a fine and/or <br /> imprisonment for known violations . (HSC 25191 ) <br /> i <br /> Name : 3l-) (Zit V L1414 ( Title : <br /> Date : <br /> Signature : <br /> li <br />