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± f <br /> San .Joaquin Cot my <br /> Environmental Health Department <br /> 1868 East Hazelton Avenue, Stockton , California 95205-6232 <br /> Telephone: (209) 468-3420 Far: (209) 46803 33 Web: www. siaov.om/ehd <br /> RETURN TO COMPLIANCI 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 farm must be submitted to the Enironmontal 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 Farm , or disputes to any <br /> Violations, are to be submittE) using this certificatlon 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 he above noted dates will be <br /> gilled at the current. hourly rate. <br /> For this certification to be complete , the cperatorofthe I tte must include: <br /> A statement documenting what corrective actions were taken or will taken for each violation <br /> Copies of sample results/manifests/training recordslother appropriate paperwork, and/or photos verifying <br /> corrections <br /> Operator's certification <br /> Inspection Date: September 25, 201 $ Inspected By : Nicholas l.oshrer <br /> Facility Address: 245 W LOUISE AVE CERS ID: 10183201 <br /> I certify under penalty of law that: <br /> � - I have corrected the violations specified In the Inspection Report frQrr the above-mentioned inspection date. <br /> w , ha y' ,personally examined the following documentation submitted s proof of compliance FOR EACH VIOLATION <br /> tl ! believe the information to be true, accurate, and complete; <br /> _ Photos <br /> Paperwork _ Statement <br /> 3, I am authorized to submit this certification on behalf of the Respond nt. <br /> 4. 1 am aware that there are significant penalties for submitting false In formation, including the possibility of a fine <br /> and/ori prisonment for known violations, (HSC 25191 ) <br /> Name: Title: <br /> Signature: �-• _Date: t _ <br /> RECEIVED I <br /> lIAR 2 9 2021 <br /> ENVIRONMENTAL HEALTH <br /> DEPARTMENT <br /> E 11 d LOOT # 908TSZ860Z eapeeds WH 8 £ 0660 TZOZ - 63 - XEI <br />