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San Joaquin County <br /> Environmental Health Department <br /> 1868 East Hazelton Avenue , Stockton , California 95205 -6232 <br /> Telephone: (209 ) 468.3420 Fax : (209) 468 .3433 Web: www sjgov . ora/ehd <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 <br /> at the top 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 <br /> billed at the current hourly rate . <br /> For this certification to be complete , the operator of the site must include : <br /> A statement <br /> documenting <br /> lation <br /> actions oo <br /> Copies of sample rsults//manifeis/tainng rcords/other appropriate paperwork , and/or photos verifying <br /> corrections <br /> Operator' s certification <br /> Lydia Baker <br /> Inspection Date : August 11 , 2021 Inspected By : <br /> Facility Address : <br /> 6131 PACIFIC AVE CERS ID : 10180905 <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 be true , accurate , and complete : <br /> Photos Paperwork Statement <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 : Title : <br /> Signature : Date: <br />