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SAN J 0 AQ U I N Environmental Health Department <br /> RETURN TO COMPLIANCE CERTIFICATION <br /> AnyIM NOR violations noted in the"Notice to Comply"in the attached Inspection Report must be r ded within 30 da s 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 reompt of the Inspection Report- HSC 25404.1.2(c)(1) <br /> All coned ions to otheryiolations noted in the attached Inspection Report(IR)or Continuation Form,or disputes to any <br /> violations,are to be submitted using this certification and retumed to END within 30 days unless otherwise spedfied 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 Ce rtlflCRtiOn t0 Ile complete, the operator of the site must induda; <br /> A statement documenting what corrective actions were taken or will be taken for each violation <br /> Copies of sample results lmanifestsltraining rocordslother appropriate paperwork,andlor photos verifying corrections <br /> Operators certification <br /> Inspection Date: April 23,2019 _ Inspected By: ELIANNA FLORIDO <br /> Facility Address: 7528 Pacific Ave,Stockton CERS ID: 10406362 <br /> l 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 following documentation submitted as proof of compliance FOR EACH VIOLATION and <br /> I believe the information to be true,accurate,and complete: <br /> Photos _paperwork V Statement <br /> 3- I 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 Tine andlar <br /> imprisonment for known violations. (HSQ 25191) <br /> Name- J� Title <br /> Signature: f Date: 1 � <br /> May 23,2019 pg.3 <br />