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SAN J OAH I N Environmental Health Department <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 in pection This certification form must be submitted to the Environmental Health Department(EHD)address at <br /> the bottom of thip form within 30 days of receipt of the Inspection Report. HSC 25404.1.2(c)(1) <br /> All corrections tc 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 Repo I HSC 25185(c)(3) <br /> Note: All EH D staff time associated with failing to comply by the above noted dates will be billed <br /> at the current hourly rate. <br /> For this e rtifieation 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 /> Operator's certification <br /> Inspection ate: March 30, 2022 Inspected By: LYDIA BAKER <br /> Facility Add ess: 10715 Trinity Pkwy, Stockton CERS ID: 10760026 <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 hay personally examined the following documentation submitted as proof of compliance FOR EACH VIOLATION <br /> and I t elieve the information to be true, accurate, and complete: <br /> Photos Paperwork Statement <br /> 3. 1 am uthorized to submit this certification on behalf of the Respondent. <br /> 4. lam ware that there are significant penalties for submitting false information, including the possibility of a fine <br /> and/ I ' risonment for known violations. (HSC 25191) <br /> Name: o'r'of ada Title: /C-1 .5) A �r <br /> Signature� <br /> l� G Date: <br />