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sQNJOQQUIN Environmental Health Department <br /> ai( <br /> -- COUNTYveewj — <br /> Grearnest grows hart. <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 �orrection � 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 day 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 resultstmanifests✓training recordslother appropriate paperwork, and/or photos verifying corrections <br /> Operator's certification <br /> Inspection Date : September 30, 2020 Inspected By : ELENA MANZO <br /> Facility Address: 5475 S VAN ALLEN RD , STOCKTON CERS ID : 10181781 <br /> I certify under penalty of law that: <br /> 1 . I have con'ected 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. I am authorized to submit this certification on behalf of the Respondent. <br /> 4. I am aware that there are significant penalties for submitting false information , including the possibility of a fine ands <br /> imprisonment for known violations. ( HSC 25191) <br /> 7 <br /> Name: C l e.fz <br /> Title : <br /> Signature : �! <br /> Date: l <br />