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PV <br /> viron enta <br /> n <br /> I Health Department <br /> S AN <br /> . ... ......... <br /> �J- -N w'"A- wY <br /> sC.- . <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 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 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 Date0: December 28 , 2022 Inspected Bye. GABRIELA GARCIA- MEJIA <br /> Facility Address .M 3845 S ELDORADO ST , STOCKTON CERS IDE. 10183601 <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 Paperwork Statement <br /> 3 . I am authorized to submit this certification on behalf of the Respondent. <br /> 1 4 . I am aware that there are significant penalties for submitting false informatio cluding the possibility of a fine <br /> and/or imrprisonmen for known violations . ( HSC 2519 '{ ) 1 1 <br /> Name : �l Title : 1 ✓"-U�- J �,�/� ? <br /> Signature : �C Date : C <br /> ��� <br />