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i® <br />:. - SAN.)JOAOUIN Environmental Health Department <br />®I 4h COUNTY.. <br />..... <br />RETURN TO `COMPLIANCE CERTIFICATION <br />Any INO 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 dgys, unless otherwise specified in the <br />Inspection Report, HSG 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 cerkification 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: Mai/ 09, 2019 Inspected By: STAGY RIVERA <br />Facility Address: 4075 E MAIN ST, STOCKTON CERS ID: 10180873 <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. I 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 />Phcftos _paperwork � Statement <br />3_ I am authorized to submit this certification <br />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 <br />imprisonment for known violations_ (HSC 25191) <br />Name: <br />Signatu <br />Title: Yv1 W-A45vC�, PD, <br />� 1 � S r S�SSm��-�� Oen � � ►�-1 �\tel , Co4� � n c�� �� , <br />0 DW <br />� 1e CW crve� num =D.0: <br />b el? �` F��2a -V �t�ciQ 1J . W msF ONO �}�2 <br />1868 E. Hazelton Avenue I Stockton, California 952051 T 209 468-3420 1 F 209464-0138 www,sjcehd.com <br />Received Time May, 9. 2019 11:42AM No, 4999 <br />