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May.09.2019 06:40 PM Waterloo Liquors 2094634114 PAGE. l/ 2 <br />San Joaquin County <br />Environmental Health Department <br />1868 East Hazelton Avenue, Stockton, California 95205-6232 <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: .s' ov.o /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 />Ail cQrf�c�ons 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 eerti#ication 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 <br />corrections <br />Inspection Date: _April 11, 2019 Inspected By: STACY RIVERA <br />Facility Addressc 2512 E WATERLOO RD, STOGKTON CERS ID: 10181585 <br />1 certify under penalty <br />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 submitt <br />ed as proof of compliance FOR EACH VIOLATION <br />and I believe the information to be true, accurate, and complete: <br />P <br />hotosPaperwork ,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 submitt <br />ing false infiormation, including the possibility of a fine <br />andJor imprisonment for known violations. (HSC 25191) <br />Signatu <br />Title: <br />Date: <br />