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_ Q I Environmental Health Department <br /> Ou NTy. <br /> . . �.i .,Y•,...., fig ir:'!' �il; <br /> RETURN TO COMPLIANCE CERTIFICATION <br /> Any MINOR violations noted in tha "Notice to Comply' in the attached Inspection Report must be corrected within 30 days of <br /> receipt of this inspection. This 00difioation form must be submitted to the Environmental Health Department (EHf3) address at <br /> the bottom of this form within 30 day8 of receipt of the Inspection Report. HSC 25404.1.2(c)(j} <br /> All-qorrections to otbor violations noted in the attached Inspection Report (Ifs)or Continuation Form, or disputes f any <br /> violations, are to be submitted using this certifioatlon end returned to EHID]within 30 days unless otherwise speorfied in the <br /> lnspection Report. HSC 25185(c)(3) <br /> Note: All EH staff time associated with failing to camply'by the above noted 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 /> A statement documenting what oorrective actions were taken or will be taker~for each violation <br /> Copies of sample res uIWmaniFestsnrain ing recordslother appropriate paperworik, andfor photos verifying corrections <br /> Operator's certification <br /> Inspection Date: September 17, 2020 Inspected By: ROBERT LOPE <br /> Facility Address: 4303 CHRISTIAN LIFE WAY, STOCKTON CERS ID: 1014 781 <br /> I certify under penalty 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 submitted as proof of compliance FOR EACH Vi0LATION <br /> and I believe the informallon to be true, accurate, and complete: <br /> Photos_Paperwork A—Statement <br /> 3. I am authorized to submit this certirication ori behalf of the Respondent. <br /> 4. 1 am aware that there are significant penalties for suhrnWing false Information, including the possibility of a fine andh <br /> frrrprilsonment for known vdolafions_ (HSC 25'191) <br /> Name: —Title.- <br /> Date: <br /> A <br />