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NJ O Q U I N Environmental Health Department <br /> RETURN TO COMPLIANCE CERTIFICATION <br /> Any MINOR vio 3tions noted in the"Notice to Comply"in the attached Inspection Report must be corrected within 30 days of <br /> receipt of this in ipection. This certification form must be submitted to the Environmental Health Department(EHD)address at <br /> the bottom of th s form within 30 days of receipt of the Inspection Report. HSC 25404.1.2(c)(1) <br /> All corrections t other violations noted in the attached Inspection Report(IR)or Continuation Form,or disputes to any <br /> violations,are t be submitted using this certification and returned to EHD within 30 days unless otherwise specified in the <br /> Inspection Rep . HSC 25185(c)(3) <br /> Note: A I EHD staff time associated with failing to comply by the above noted dates will be <br /> billec at the current hourly rate. <br /> For this c rtification to be complete, the operator of the site must include: <br /> A statE ment documenting what corrective actions were taken or will be taken for each violation <br /> CopieE of sample resultslmanifestsltraining records/other appropriate paperwork,and/or photos verifying corrections <br /> Opera is certification <br /> Inspection I late: January 26, 2021 Inspected By: CAROL PRESTO <br /> Facility Adc ress: 2575 COUNTRY CLUB BLVD, STOCKTON CERS ID: 10118074 <br /> I certify under ienalty of law that: <br /> 1. 1 hay corrected the violations specified in the Inspection Report from the above-mentioned inspection date. <br /> 2. 1 ha personally examined the following documentation submitted as proof of compliance FOR EACH VIOLATION <br /> and I elieve the information to be true, accurate,and complete: <br /> Photos Paperwork _Statement <br /> 3. 1 am iuthorized to submit this certification on behalf of the Respondent. <br /> 4. 1 am ware that there are significant penalties for submitting false information,including the possibility of a fine and/or <br /> imph nment for known violations. (HSC 25191) <br /> Name: 1 A 9A rJ,3 -+ rpt - Title: 1`I )t,)A Gr <br /> Signatu e: � Date: I___��� <br />