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i <br /> 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.sIg oa v. org/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 (I R) 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 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 <br /> corrections <br /> Operator's certification <br /> Inspection Date: June 22, 2017 Inspected By : Robert Lopez <br /> Facility Address: 14201 W HWY 4 CERS ID : 10180769 <br /> 1 certify under penalty of law that: <br /> 1 . I 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. 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 /> Name: Title: <br /> Signature: Date: <br />