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i <br /> Environmental Health Department <br /> SANJOAQUINCC)IJ NTYr <br /> 1 ETUI N TO COMPLIANCE CERTIFICATION <br /> N <br /> Any MINQR violations noted in the "Notioe to Comply" in the attached Inspection Report must be corrected withln 50 dais 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 farm within 30 days of receipt of the Inspection Report. HSC 25404.1.2(c)(1) <br /> All corrections to other vlolations hated in tfte attached Inspection Report(IR) or Continuation Form, or disputes to any <br /> Violations, are to ba submitted using this certification and returned to EHD within 30 dsysdsys 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 thi certification to be oorrlplete, 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 res uItsirnanifestsltraining records/other appropriate paperwork. andlor photos verifftpi corrections <br /> Operator's certification <br /> Inspection Date: September 18, 2020 Inspected By: ROBERT LOPE <br /> Facility Address: 23031 est Ln, Stockton CERS ID: 10142398 <br /> certify under penalty of law that: <br /> 1. l have corrected the violations specified in the Inspection Report from the above-men Uoned inspection date, <br /> 2. 1 have personally examined the following documentation submitted as proof of compliance FOR EACH VIOLATION <br /> and I helieve the information to be true. accurate, and complete: <br /> Photos Paperwork 1� Statement <br /> 3. I 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 possibllity of a fine and/( <br /> imprisonment for known violations. (HSC 25191) <br /> r4mrrd carp <br /> Name: Title: <br /> signature: - Date: i <br /> i <br /> i <br /> i <br /> i <br />