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S- A- N.1 �0 A 0. U. IN <br />--� c cru N T`%�..__. <br />GF, i7.1 f P e 5 � 9 r e) �--;o � hrere <br />Environmental Health Department <br />RETURN TO 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 <br />inspection,, This certification form <br />must <br />be submitted to the <br />Environmental Health Department { <br />the bottom of <br />this form within 30 days of receipt <br />of the <br />Inspection Report. <br />HSC 25404.1.2(c)(1) <br />EHD) address at <br />Al! 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. FISC 25185(cX3} <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 records/other appropriate paperwork, and/or photos verifying corrections <br />• <br />Operator's certification <br />Inspection Date: June 21, 2021 Inspected By: ROBERT LOPEZ <br />Facility Address: 4301 NEWTON RD, STOCKTON CERS ID: <br />I certify under penalty of haw that: <br />101840Q9 <br />1. I have corrected the violations specified in the Inspection Report from the above-mentioned inspection dale. <br />2. ! have personalty 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 /1*'�_Statement <br />3. [ am authorized to submit this certification on behalf of the Respondent. <br />4, I 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:---,,�cc:������.3 <br />z <br />Signature-. <br />0 <br />I <br />Title: <br />Date: <br />