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i <br /> I <br /> k� I Environmental Health Department <br /> SAN} <br /> COUNTY- <br /> RETURN <br /> OUNT -F ETURN TO COMPLIANCE CERTIFICATION <br /> Any MINA violalians noted In the "Notice to Comply' in the attached Inspection Report must be corrected within 30 day_*,of <br /> receipt of this inspection. This coMfication form must he submitted to the Environmental Health Deparlment (EH D)address at <br /> the bottom of this form within 30 days of receipt of the Inspection Report. HSG 25404,1.2(c)(1) ; <br /> All corrections tickler violations noted in the attached Inspection Report(IR) or Continuation Form, or dispukes to any <br /> Violations. are to be submitted using this certification and returned to EHD within 30 dam.unless otherwise specified In-the <br /> Inspection Report, HSC 25185(c)(3) <br /> Note: All EHD staff time associated with falling to comply by the above noted dates will be <br /> billed at iha 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 token for each violation <br /> Copies of sample rig sultsfmanifestsltraioirig recordslothor appropriate paperwork, andlor photos verifying corrections <br /> Operator's certificatlon <br /> Inspection Date, September 18, 2020 Inspected By. ROBERT LOPE <br /> Facility Address: 1640 N Broadway Ave, Stockton oERS 1D: 10145395 <br /> I certify under penalty of law that; <br /> I- l have corrected the violations specified in the Inspection Report frarn the above-mentioned inspection date_ <br /> 2. 1 have personally examined the following documentatlon Submitted as proof of compliance FOR EACH VIOLAT10N <br /> and I iretre the lydcrmalrcn to be live, accurate, and car e; <br /> Photos Paperwork Steternent <br /> 3, r am authorized to submit this certification on behalf of the Respondent. <br /> 4. 1 am awe re that there are significant penalties for submitting false information, including the possINity of a fine and/( <br /> imprisonment for known violations. (HSC 25191) <br /> Name. "MWW Title; <br /> Signature: bate: <br />