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y Environmental Health Department <br /> t;� �:":� � �( 14;1 '-1- �.• <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 /> the bottom 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 results/manifests/training records/other appropriate paperwork , and/or photos verifying corrections <br /> Operator's certification <br /> Inspection Date : May 01, 2019 Inspected By : STACY RIVERA <br /> Facility Address : 7611S AIRPORT WAY , STOCKTON CERS ID : 10181317 <br /> I 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 <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 submitting false information , including the possibility of a fine and/ <br /> imprisonment for known violations , (HSC 25191 ) <br /> ,./� ��!/� <br /> Name : g GTitle: el�6y'�j� /��,1a ivf <br /> Signature : /J at� `lll Date: <br /> f 1, <br /> 1868 E , Hazelton Avenue I Stockton , California 95205 1 T 209468 - 34201 F 209464-0138 1 www. sjcehd. com <br />