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SAl\|"-JOAOU Ihl <br />Environmental Health DePartment <br />.{ _.,.. <br />COUNTY" <br />(rr,',i,rr..; i iJt f.'1r,1 Jl.rr I <br />RETURN TO COMPLIANCE CERTIFICATION <br />Any MINOR violations noted in the "Notice to Comply" in the attached lnspection Report must be corrected within 30 days of <br />re""ipt 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 lnspection Report, HSC 25404.1 .2(c)(1) <br />All corrections to other violations noted in the attached lnspection Report (lR) or Continuation Form, or disputes to any <br />viotations, are to be suUmitt"O using this certification and returned to EHD within 30 days unless othenvise specified in the <br />lnspection Report. HSC 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 />FOf this CeftifiCatiOn 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 resultsTmanifests/training records/other appropriate paperwork, and/or photos verifying corrections <br />' Operator'scertification <br />lnspect ion Date: August 16,2021 lnspected By:ROBERT LOPEZ <br />Facility Address: 2455 Teepee Dr, Stockton CERS lD: 10748761 <br />I certify under penalty of law that: <br />j. I have corrected the violations specified in the lnspection Report from the above-mentioned inspection date <br />2. I 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 />-Pho <br />to" / Paperuuork / <br />"rurement <br />3. I 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:tt tcho lorr J'cor'ri Title ogorqt ionJ speciCI liJ t <br />Signatu Date:oll01l2t