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Environmental Health Department <br /> Y1lAQUIN <br /> SAN <br /> WF <br /> v IV <br /> RETURN TO COMPLIANCE CERTIFICATION <br /> Aeport must be of <br /> ny MINOR violations noted in the "Notice to Comply in the attachedo the Entv�o amen al Health Department ( EHD) address at <br /> receipt of this inspection . This certification form must be submitted <br /> the bottom of this form within 30 days of receipt of the Inspection Report. HSC 25404 . 1 .2(c)( 1 ) <br /> sputes to <br /> All Gorrections to other violations noted in the attached ard returned dction Report (IR) or to EHD within 3ont0 des. unless otherwion Form , or se specified in the <br /> violations , are to be submitted using this certification <br /> Inspection Report . HSC 25185(c)(3) <br /> Note : All EHD staff time associated with failing to comply by the above Hated 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 /> lation <br /> A statement documenting what corrective actions were taken or will be takefooeandioach �photos verifying corrections <br /> Copies of sample results/manifests/training records/other appropriate pape k <br /> Operator's certification <br /> : <br /> Inspection Date _ September 27 ,' 2019 <br /> Inspected By: PAUL NSO <br /> Facility Address: 4747 WEST LN , STOCKTON <br /> CERS ID: 10181343 <br /> I HE liiiiiiiiiii I ME 1 11 11 11111 1 111111 11111 ME <br /> I certify under penalty of law that: <br /> 1 . I have corrected the violations specified in the Inspection Report from the above<mentioned inspectio7VIOtLAT <br /> 2. 1 have personally examined the following documentation submitted as proof of compliance FOR EAC <br /> and I believe the information to be true, accurate, and complete: <br /> Photos Paperwork Statement <br /> 36 i am authorized to submit this certification on behalf of the Respondent. <br /> 4. I am aware that there are significant penalties C 2submitting false information ,including the possibility of a fine <br /> andlor imprisonment for known violations . (HS ) <br /> Name: <br /> MINIMUM w�rint�F � Sl « H Title: �- <br /> Signature. Date: <br />