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SAW-JOAQUIN Environmental Health Department <br /> — <br /> COUNTY <br /> RETURN <br /> ...-.- <br /> RETURN TO COMPLIANCE CERTIFICATION <br /> Any MIMI^NCR violations noted in the"Notice to Comply" in the attached Inspection Report must be corrected within 30 do--S 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 viofations 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 <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 results/manifests/training records/other appropriate paperwork, and/or photos verifying corrections <br /> Operator's certification <br /> Inspection Date: May 20, 2021 Inspected By: FREDERICK ERNEST <br /> Facility Address: 641 S Harrison St, Stockton CERS ID: 10723408 <br /> 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. 1 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 andk <br /> imprison r known ioJations. (HSC 25191) <br /> Name: <br /> Title: <br /> Signature- Date: _ v — <br /> G <br />