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SAN JQQQUIN Environmental Health Department <br /> w -----C a U N T Y___w. <br /> Far <br /> ,- reotness grows here, <br /> W, <br /> ae RETURN TO COMPLIANCE CERTIFICATION <br /> Ins <br />_ <br /> In n Any MINOR violations noted in the"Notice to Comply"in the attached Inspection Report must be corrected within 30 days of <br /> R receipt of this inspection. This certification form must be submitted to the Environmental Health Department(EHD)address at <br /> coi the bottom of this fixm within 30 days of receipt of the Inspection Report, HSC 25404.1.2(c)(1) <br /> 71 <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) V <br /> r <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 /> 1 For this certification to b <br /> ia 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 /> L Copies of sample results/manifests/training records/other appropriiate paperwork,and/or photos verifying corrections <br /> II1 Operator's certification <br /> H; <br /> Inspection Date: February 09, 20,21 Inspected By: STACY RIVERA <br /> — <br /> rs' Facility Address: 437 N WILSON INAY, STOCKTON CERS ID: 10180899 <br /> s.: <br /> sc I certify under penalty of law that: <br /> c 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 /> 2 r <br /> 2, __Photos Paperwork Statement <br />', 3. 1 am authorized to submit this certification on behalf of the Respondent. <br />'5 <br /> s <br /> 4. 1 am aware that there are significant penalties for submitting false information, including the possibility of a fine and/or <br /> imprisonment for known violations. (HSC 25191) <br /> Title: <br /> Si ur •_ <br /> �_ I <br />