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SAN 1 O A Q 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 dovs of <br /> receipt of this inspection. This certification form most be submitted to the Environmental Health Department(EHD)address at <br /> the bottom of this form within 30 days of receipt of the Inspection Report. HSC 25404.1.2(c)(1) <br /> All connections to other violations noted in the attached Inspection Report(IR)or Continuation Farm,or disputes to any <br /> violations,are to be submitted using this certification and resumed m EHD within 30 days unless otherwise specified in the <br /> Inspection Report. HSC 25165(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/manifestsilmuning recordslother appropriate paperwork,and/or photos verifying corrections <br /> Operators certification <br /> Inspection Date: August 07, 2019 Inspected By: CESAR RUVALCABA <br /> Facility Address: 9010 HOWARD RD, STOCKTON CERS ID: 10185577 <br /> 1 certify under penalty of law that: <br /> 1. I have corrected the violations specified in the Inspection Report from the above-mentioned inspection date. <br /> 2. 1 have personally examined the follomrij documentation submitted as proof of compliance FOR EACH VIOLATION and <br /> I believe the information to be true,accurate,and complete: <br /> —Y–Photos Paperawrk�Slatement <br /> 3. 1 am authodzad to submit this certification an behalf of the Respondent. <br /> 4. 1 sin aware that there are significant penalties far submiltng false information,including the possibility of a fine andlor <br /> imp risopment for known viol ns. (HSC 251,91) <br /> Name: till �l (( ( Title: <br /> Signature: Date: C <br /> 1868 E.Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjcehd.com <br />