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saN JU UIN <br />Ci?lJ l%J TY <br />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 dans of <br />receipt of this inspection. This certification form must be submitted to the Environmental Health Department (EHD) address <br />at the bottom of this form within 30 days of receipt of the Inspection Report. HSC 25404A 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 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 ofthe 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: June 24, 2019 Inspected By: _ <br />ANIZ <br />Facility Address: 10848 S HARLAN RD, FRENCH CAMP CERS ID: <br />certify under penalty of law that: <br />JOHN AL <br />10184373 <br />1. I have corrected the violations specified in the Inspection Report from the above-mentioned inspection date. <br />2. I 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 comp) te: <br />`/ fz <br />Photos Paperwork Statement <br />3. I am authorized to submit this cert <br />ification on behalf of the Respondent. <br />4. I am aware that there are significant penalties for submitt <br />ing false information, including the possibility of a fine and/or <br />imprisonment for known violations. (HSC 25191) <br />Name: <br />Signature: Date: <br />IUI_.24 2019 <br />EN��1�ONlUfENI`A1. <br />464-0138 1 <br />www.sjcehd.com <br />Title: %?2�-, <br />1868 E. Hazelton Avenue � Stockton, California 95205 � T 209 468-3420 I F 209 <br />