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SAN J 0 AQ U l 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 corrQcted wilhin 30 days of <br /> receipt of this Inspeclion. This certification form must be submitled to the Environmental Health Department(EHD)address at <br /> the bottom of this form within 36 days of receipt of the Inspection Report. HSC 25404.1.2(c)[1) <br /> All corrections to other violalions noted in the attached Inspection Report 0R}or Continuation Form,or disputes to any <br /> violations,are to be submitted using this certification and returned to[HD within 30 days unless otherwise spocifiod 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 he complete, the operator of the site must include: <br /> A statement documenting whal corrective actions were taken or will be taken for each violation <br /> Copies of sample results/manifests/training recordslother appropriate paperwork,andlor photos verifying corrections <br /> Operator's certification <br /> Inspection Date: ,May 15,2019 Inspected By: ELIANNA FLORIDO <br /> Facility Address: 318 W MAIN ST.RIPON CERS ID: 16772860 <br /> I certify under penalty of law that- <br /> 1. 1 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 and <br /> 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, I am aware that there are significant penalties for subrnitting false information,including the possibility of a fine andlor <br /> imprisonment for known violations. (HSC 25i <br /> 91) ! s <br /> Name: Vl 1 Title: M � <br /> Signature. Date: J UkA <br /> 1868 E.Hazelton Avenue I Stockton,California 95205 I T 209 468-3420 I F 209 464-0138 1 www.sjcehd.corn <br /> July 22,2019 pg.2 <br />