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SAN J OAQ I N f nvorr® nrnen@ en. -ea si' c� DepaiiLIMM4: <br /> c _ Ui11Y <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 days of <br /> receipt of this inspection . This certification form must be submitted to the Environmental Health Department ( EHD ) address <br /> at the top of this form within 30 days of receipt of the Inspection Report. HSC 25404. 1 . 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 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 resultslmanifests/training recordslother appropriate paperwork , and/or photos verifying <br /> corrections <br /> Operators certification <br /> Inspection Date : May 09 , 2018 Inspected By : LYDIA BAKER <br /> Facility Address : 4715 N WEST LN , STOCKTON CERS ID : 10183177 <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 , 1 have personally examined the following documentation submitted as proof of compliance FOR EACH VIOLATION <br /> and I believe the information to he true , accurate , and complete: <br /> V Photos _Paperwork V/ Statement, <br /> 3G 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 fine <br /> and/or imprisonment for known violations . ( HSC 25191 ) i <br /> Name : (' �(t,\ S fAC4 lrrn� rt--' Title : S•iZN `Q dv�A�raR•�r' <br /> i <br /> Signature : C�3t, Kqk� Date : el& ' 2 I t <br /> l <br /> 1 <br /> i <br /> i <br /> t <br /> i <br /> I <br /> r <br /> 1868 E . Hazelton Avenue 1 Stockton , California 95205 1 T 209 468-34201 F 209 464 -0138 1 www. sicehd . com <br /> i <br />