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i <br /> I Environmental Health Department <br /> SKJOAH <br /> COUNTY' <br /> RETURN TO COMPLIANCE CERTIPICATION <br /> Any iNOR violations noted in the"Notice to Comply" in the attached Inspection Report must be corrected within 3Q �of <br /> receipt of this inspection. This certificatlon form must be submitted to the Envirorrmw(aI Health Department(EHD) address at <br /> the bottom of this form within 30 days of receipt of the Inspection Report. HSC 5404,1.2-(c)(1) <br /> A11 corrections to other violations noted in the attached Inspection Report (IR) or Continuation Form, or disputes to any <br /> v+olations, are to be submitted using this certification and returned to EHD within 30 dates unless otherwise speclfied in the <br /> Inspection Report. HSC 25185(c)(3) ' <br /> Note: All EH staff time associated with failing to comply by the above noted dates will be <br /> billed at the currant hourly rate. <br /> For this certification to be complete,, the operator of the site must include: <br /> A statement documenting what oorrecuve actions were taken or will be taken for each violatlon <br /> Copies of saw pie resultsfmanifeststtraining recordslother appropriate paperwork, andlor photos verifying oorrectioris <br /> operator's certification <br /> Inspection Date: September 16, 2020 Inspected By: ROBERT LOPEZ <br /> Facility Address: 6737 Herndon PI, Stockton CERS ID: 101 42707 <br /> I certify under penalty of law that; <br /> 1. 1 have corrected the vil6lations specified in the Inspectlon Report from the above-mentioned inspection date. <br /> . ' 1 have personally examined the following documentatlon submitted as proof of cornpiiance FOR EACH VI0LATION <br /> and I believe the Informakion to be true, accurate, and complete; <br /> Photon __Paperwork X-3 LaLernent <br /> 3. 1 am authorized to submit this certification on hehalf of the Respondent. <br /> 4. 1 am aware that there are significant penalties for submitting false information, including the possibility of a fine andh <br /> imprisonment for known violations, (H3C 25 191) <br /> Name: +v-baryd°ftWorE",.jM,j ow"W" Title; <br /> Signature: _bate: <br />