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SAN �� Q I Environmental Health'D partm nt <br /> ,C OLJ1 T <br /> RETURN TO COMPLIANCE CERTIFICATION <br /> Ahy MINOR violations noted in the°Notice to Comply' In the attached Inspection Report mUst be corrected+ 1hin 30 dans of <br /> receipt of this inspection. This certification form most be submitted to the Environmental Health Department(eHD) address at <br /> (lie boUartt of tfrrs forra wkhM 30 days o€rec*t of the krspec kwi Repan. HSC 25404.1,2(cM?) <br /> All corfecfions tvoiber violations nated in the attached Inspection Report (IR) or Conti nualion Form, or disputes to any <br /> violations, are to be submitted using this certification and returned to EHO within10 +Ls unless Otherwise specified in the <br /> Inspection Report. HSC 25185(c)p) <br /> Note: All EHD staff time associated wlth failing to comply by the above noted dates w111 be <br /> billed at the current hourly rate. <br /> Forthis ertifi atiOn to be complete, the operator of the site must include: <br /> A staternent documenting what corrective actlons were taken or will be taken for each viotatlon <br /> Copies of sam pie resultsfmanifestWtraining records/other appropriate paperwok andlor photos verifying corrections <br /> Operator's cerfMca{oii <br /> Insper-Hon Date: September 17, 2020 Inspected By: ROBERT LOPE <br /> Facility Address: 988 Gii11is Rd, Stockton CERS ID: 10145393 <br /> codlfy under penalty of law that: <br /> 1. 1 have corrected the violations specified in the Inspection Report from the above-mentioned inspection date. <br /> 1 have personally examined the following documentation submitted as proof of compliants FOR EACH VIOLATION <br /> and I believe the information to be true, accurate, and complete: <br /> Photos Paperwork 2S1.1statemant <br /> 3. 1 am authorized to submit this certification on behalf of the Resbondent. <br /> 4_ 1 am aware that there are significant penalties for submitting Use informa#ion, including the possibility of a fine andlc <br /> imprlsonment for known violations. (HSC 25191) <br /> IYnr�prrpregq„�,�� � <br /> Name: Title; <br /> Signature: _ _ bate; <br />