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�, t Environmental Health Department <br /> SAM ;JQ QUIAA '' <br /> �1 <br /> C0Ur rY <br /> r <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 <br /> at the top 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 ( IR) 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 rete. <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 <br /> corrections <br /> Operators certification <br /> Inspection Date, June 18, 2019 Inspected By : SHEWIT WOLDEAREGAY <br /> Facility Address : 3304 W HAMMER LN , STOCKTON CERS ID : 10184253 <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 VIOLATION <br /> and I believe the information to be true , accurate, and complete : <br /> Photos 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 <br /> and/or imprisonment for known violations . (HSC 25191 ) <br /> i <br /> Name : VECl� h' Title : <br /> Signature : l�G�— Date : <br /> 1868 E . Hazelton Avenue I Stockton . California 95205 1 T 209 468-3420 1 F 209 4640138 1 mvw. sjcehd . com <br />