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s A N J o A Q U i N Environmental Health Department <br /> COUNTY --A <br /> RETURN TO COMPLIANCE CERTIFICAT2022 <br /> Any MINOR violations noted in the " Notice to Comply!' in the attached Inspection Report must r fllwltwtkda s of <br /> receipt of this inspection. This certification form must be submitted to the Environmental'04� ` �yp/grfitflV � ) address at <br /> the bottom 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 (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) <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 /> Operator's certification <br /> Inspection Date: October 19, 2022 Inspected By: ROBERT LOPEZ <br /> Facility Address : 1549 N BROADWAY AVE , STOCKTON CERS ID: 10183783 <br /> I 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 X Paperwork XStatement <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 andh <br /> imprisonment for known violations. (HSC 25191 ) <br /> Name: Ban Idarnill, Title: OFD Z 6FOMZI &W429e (' <br /> Signature : ` Date: /i /iy�2y2 2 <br /> L <br />