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• May. 09.2019 07:39 PM Waterloo Liquors 2094634114 PAGE. 1/ 2 <br />San Joaquin County <br />Environmental Health Department <br />1868 East Hazelton Avenue, Stockton, California 95205-6232 <br />Te%phone: (209) 468-3420 Fax: {209) 468-3433 Web: www.sjgov.or /g ehd <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 pQrf��tions to other violatiorZs 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 withig 30 days unless otherwise specified in the <br />Inspection Report. HSC 25185(c)(3) <br />Nota: All EHD staff time associated with failing to comply by the above noted dates wilt 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 betaken far each violation <br />Copies of sample resultslmanifestsltraining records/other appropriate paperwork, and/or photos verifying <br />corrections <br />Inspection Date: April 11, 2019 Inspected By: STACY RIVERA <br />Facility Address; 2512 E WATERLOO RD, STOCKTON CERS ID: 10181585 <br />l certify under penally 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 />and 1 believe the information to be true, accurate, and complete: <br />Photos Paperwork ��Statement <br />3. I 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 <br />and/or imprisonment for known violations. (HSC 25191) <br />Name: <br />Signature: <br />Title: <br />-cr�"" <br />