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; - <br /> SAN 10AQ U I PJ Environmental Health Department <br /> c o u N T Y Received 08/03/2021 <br /> C". ircotness grows h <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 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 Ibe submitted using this certification and returned to EHD within 30 days unless otherwise specified in the <br /> Inspection Reporit. HSC 25185(c)(3) <br /> Note: All EHID 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: July 07, <br /> 2021 Inspected By: VICKY YANG-LEE <br /> Facility Address: 5611 E WATERLOO RD, STOCKTON CERS ID: 10180881 <br /> I certify under penalty of law that: <br /> 1. 1 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 Ibe 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 <br /> and/or imprisonment for known violations. (HSC 25191) <br /> t� Title:_ Q(-0 VIeN( <br /> C'% Date: <br /> Signature: 1 <br />