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Environmental Health Department <br /> SAKJOAQUIN <br /> i�K yam <br /> s, Greatness graves here. <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 at <br /> the bottom of this form within 30 days of receipt of the Inspection Report. HSC 25404.1.2(c)(1) <br /> All corrections to other violations noted in the attached Inspection Report(1R)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 certification 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 corrections <br /> Operator's certification <br /> Inspection Date: October 22, 2019 Inspected By: SHEWIT WOLDEAREGAY <br /> Facility Address: 1340 W Colony Rd, Ripon CERS ID: 10402351 <br /> 1 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 VIOLATION and <br /> believe the information to be true, accurate, and complete: <br /> O <br /> Photos v/ Paperwork Statement <br /> 3. 1 am authorized to submit this certification on behalf of the Respondent. <br /> 4. 1 am aware that there are significant penalties for submitting false information, including the possibility of a fine and/or <br /> imprisonment for known violations. (HSC 25191) <br /> Name: if t j 'r# Title: L y <br /> Signature: Date: 1 o -- I:)-- � <br /> 1868 E. Hazelton Avenue� Stockton, California 95205 1 T 209 468-34201 F 209 464-0138 1 www.sjcehd.com <br />