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SAN J U A Q U I N <br /> �t.j I"t _i Y Received by the SJCEHD (CM) <br /> on 06/10/2021 <br /> RETURN To C OMPUAHGE GER'11i1Ir' CATION <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 Dopartment(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 records/other appropriate paperwork, and/or photos verifying corrections <br /> Operator's certification <br /> Inspection Date: May 06, 2021 Inspected By: CLAUDIA MURO <br /> Facility Address: 1627 S CENTER ST, STOCKTON CERS ID: 10133307 <br /> I certify under penalty of law that: <br /> 1. I have corrected the violations specified in the Inspection Report fi•om 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 kZ Statement <br /> 3. 1 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: L 6l 6) 11L s Title: <br /> Signature: i Date: 5&t z <br />