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Environmental Health Department <br /> SANDAIJ <br /> SIN <br /> ihxPF." wv...xsst.�"•` y } . g �_Y Y'nr. a.. <br /> RETURN TO COMPLIANCE CERTIFICATION <br /> Anyivj INQ, 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 certlficatiori form must 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 26404. 1 .2(c)( 1 ) <br /> All co est_, _, _ons 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 corrections <br /> Operator's certification <br /> Inspection Date : July 15 , 2019 Inspected By: CLAUDIA MURO <br /> Facility Address . 301 W KETTLEMAN LN , L ODi CIrRS ID : 10187759 <br /> I cerM/ 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 following documentation submitted as proof of compliance FOR EACH VIOLATION <br /> and I believe the Information to be true , accurate, and complete : <br /> ✓Photos \*#�Popenuork ✓ 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: l wim& lN OAZ Title : OW40600 <br /> Signature : <br /> - Date: Flalf <br /> 1868 E. Hazelton Avenue i Stockton, California 95205 I T 209 468.3420 I F 209 464-0138 1 www.sjcehd.com <br /> I <br /> i <br />