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RECEIVED <br />JUL <br />17 2023 <br />cNVIK NIILINIAU Ill frtrii <br />S <br />AN J O A Q U I N DEI'ARTNIENT Environmental Health Department <br />RETURN TO COMPLIANCE CERTIFICATION <br />Any <br />MINOR <br />violations noted <br />in the "Notice to Comply" <br />in the attached Inspection Report <br />must be corrected <br />within <br />30 <br />days of <br />receipt of this inspection. This <br />certification form must <br />be submitted to the Environmental <br />Health Department (EHD) address at <br />the bottom of this form within <br />30 days of receipt of the <br />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 Date: June 27, 2023 Inspected By: KRISTINA SAETERN <br />Facility Address: 1756 N WILSON WAY, STOCKTON CERS ID: 10180819 <br />I cert <br />ify 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. I 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 -\ Z <br />Paperwork Statement <br />3. I am authorized to submit this certification on behalf of the Respondent. <br />4. I am aware that there are significant penalties for submitt <br />ing false information, including the possibility of a fine <br />and/or imprisonment for known violations. (HSC 25191) <br />Name: ASH(`.-!�( T-)UVESN Title: OfiADn1 E <br />Signature: <br />Date: <br />