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Apr 01 21 , 11 : 15p p . 2 <br /> SAN J DAQU I N Environmental Health Department <br /> - 0 1 N47 ,1 <br /> RETURN T4 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 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 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 recordslother appropriate paperwork, and/or photos verifying corrections <br /> Operator's certification <br /> Inspection Date% March 30 , 2021 Inspected By : VICKY VANG-LEE <br /> Facility Address : 7908 N ELDORADO ST, STOCKTON CERS ID : 10181259 <br /> I 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 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. 1 am aware that there are significant penalties for submitting false information , including the possibility of a fine <br /> andtor imprisonment for known violations . (HSC 25191 ) <br /> Name: Y-1 -6VA Title: lz )ot r <br /> n <br /> Signature: Date: ��� <br />