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O D C O fD C <br /> O M� � G T A <br /> Z <br /> S A N J O A O U I N 7 <br /> Environmental Health Department Q a) s rt cn <br /> r S SL N `G rF <br /> �^ n '•'� a) <br /> ° D = n <br /> v N <br /> s _ O r, <br /> RETURN TO COMPLIANCE CERTIFICATION � N' _ Ln -' _ <br /> O <br /> Any MINOR violations noted in the'Notice to Comply"in the attached Inspection Report must be corrected within 30 days of � (XI A '—' <br /> receipt of this inspection. This certification form must be submitted to the Environmental Health Department(EHD)address at ,..' 7 -0 N <br /> the bottom of this form within 30 days of receipt of the Inspection Report. HSC 25404.1.2(c)(1) �• (D N N Ln <br /> Ln <br /> I, <br /> All corrections to other violations noted in the attached Inspection Report(IR)or Continuation Form,or disputes to any W, a O ^v <br /> violations,are to be submitted using this certification and returned to EHD within 30 days unless otherwise specified in the 0 'CJ Ul O <br /> Inspection Report. HSC 25185(c)(3) 3 Ul N <br /> 3 �• D ^ T <br /> O CJ <br /> Note: All EHD staff time associated with failing to comply by the above noted dates will be billed G W <br /> at the current hourly rate. Q W m <br /> 0'4 <br /> W. <br /> (D <br /> V i7 <br /> For this certification to be complete, the operator of the site must include: h O <br /> A statement documenting what corrective actions were taken or will be taken for each violation S 3 <br /> Copies of sample results/manifests/training records/other appropriate paperwork,and/or photos verifying corrections (D V 77 <br /> Operator's certification O' S <br /> v <br /> Inspection Date: July 19,2022 Inspected By: STACY RIVERA v 77 <br /> N <br /> O <br /> Facility Address: 5611 E WATERLOO RD,STOCKTON CERS ID: 10180881 0' '-* <br /> r O_ <br /> I certify under penalty of law that: <br /> O <br /> 1. I have corrected the violations specified in the Inspection Report from the above-mentioned inspection date. 7 3 <br /> O <br /> 2. 1 have personally examined the following documentation submitted as proof of compliance FOR EACH VIOLATION rr <br /> (1 <br /> and I believe the information to be true,accurate,and complete: <br /> n• <br /> Photos `Paperwork 1'�Statement <br /> 777 <br /> 3. 1 am authorized to submit this certification on behalf of the Respondent. <br /> O <br /> 4. 1 am aware that there are significant penalties for submitting false information,including the possibility of a fine 0 <br /> and/or imprisonment for known violations. (HSC 25191) 0 <br /> rD <br /> ` �i)w. 7 <br /> Name: r�^-rc'� � �%„cl Title: m <br /> g <br /> Si nature: Date: <br /> 3 <br /> 7 <br /> c <br /> 7 <br /> O <br /> c <br /> rD <br /> rD <br /> n <br /> O <br /> ao <br /> 7 <br /> N <br /> Vie.; m <br />