Laserfiche WebLink
_�.�"• ' Environmental Health Department <br /> -`....._C p U N T Y- .-- <br /> GrfOtn�Ss gro�:s hCrC, <br /> RETURN TO COMPLIANCE CERTIFICATION <br /> Any MINOR violations <br /> receipt of this ins noted in the"Notice to Comply"In the attached Inspection Report must be corrected within 30 days of <br /> the bottompection <br /> . This certification form must be submitted to the Environmental Health Department(EHD)address at <br /> of this form within 30 days of receipt of the Inspection Report, HSC 25404.1.2(c)(1) <br /> All corrections to <br /> violations, other violations noted in the attached Inspection Report(IR)or Continuation Form,or disputes to any <br /> 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 billed <br /> 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: January 24, 2023 Inspected By: GABRIELA GARCIA-MEJIA <br /> Facility Address: 5777 S FRENCH CAMP RD, STOCKTON CERS ID: 10182157 <br /> r1ce7rtify 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_Paperwork Statement <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 25191) <br /> Name: Title: �Q <br /> Signature: Date: 162 <br /> C <br /> Created With Tiny Scanner <br />