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S I N Environmental Health Department <br /> T" Ty <br /> RETURN TO COMPLIANCE CERTIFICATION <br /> Any MINOR violations noted in the"Notice to Comply" in the attached Inspection Report must be corrected within 130 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 (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 billed <br /> at the current hourly rate. <br /> For this certificatiop 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 res Its/manifests/training records/other appropriate paperwork, and/or photos verifying corrections <br /> Operator's certification <br /> Inspection Date: Nov tuber 10, 2020 Inspected By: ROBERT LOPEZ <br /> Facility Address: 3834. DUCK CREEK, STOCKTON CERS ID: 10765612 <br /> 1 certify under penalty of law that: <br /> 1. I 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 V OLATION <br /> and I believe the info oration to be true, accurate, and complete.- <br /> Photos <br /> omplete:Photos e/ Paperwork Statement <br /> 3. 1 am authorized to SL bmit 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 /> Name: � >2tSr�P tl Title: NE't-PI MON A x <br /> Signature: Date: 12 0'1 1 202-0 <br />