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06 / 28 / 2019 19023 8387674 EMILS PAGE 04 <br /> Environmental Health Department <br /> sAN . : JOAQUIN <br /> `C,, 1 tea' vOT, Y . . . . .. . <br /> : a 40. AI <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 bottom of this form within 30 days of recelpt of the Inspection Report, HSC 25404, 1 . 2(c)( 1 ) <br /> Allcorre i n to other violation, 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, H5C 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 _ May 29 , 2019 Inspected By : ZUNn BARKER <br /> Facility Address : 1405 CALIFORNIA ST , ESCALON CERS ID : 10180567 <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 eiXamined the following documentation submitted as proof of compliance VOR EACH VIOLATION <br /> and I believe the information to be true, accurate , and complete: <br /> Photos Paperwork V 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 and/or <br /> imprison t for known violatio ( HSC 25191 ) <br /> (^ �< � ✓ <br /> Name : 1'►'1,(✓'. - \ Q, 1'itle :�� C-C 1 CSS <br /> x � p <br /> Signatur Date : L 1 <br /> RECEIVED <br /> JUN 2 8 2019 <br /> ENVIRONMENTAL IIEAurn <br /> DENARTINIEW <br /> 1868 E . Hazelton Avenue I Stockton , California 952051 T 209 46834201 F 209 464 -0138 i www. sjcehd . com <br /> Received Time Jun , 28 . 2019 7121PM No , 5221 <br />