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SAN ,JOAQUIN Environmental Health Department <br /> V —COUNTY— <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 forth 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 Forth,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 corrections <br /> Operators certification <br /> Inspection Date: January 25,2022 Inspected By: ELIANNA FLORIDO <br /> Facility Address: 130 S WILSON WAY,STOCKTON CERS ID: 10181227 <br /> 1 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_ZStatement <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 2//511191) <br /> Name: I NQ !I Title: ,G/w'W_A� <br /> Signature: Date: <br /> Scanned with CamScanner <br />