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nn AQUIN RECEIVED Environmental Health Department <br /> SANJ <br /> !.�•: ; . . _,_ ._ O t.t I T _,...W„ JUN 19 2024 <br /> r , `` reafr ess grrws here , <br /> ENVIRONMENT�En <br /> NT <br /> . IAN <br /> RETURN T &&bMP CE 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 <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 : Inspected By : <br /> Facility Address : CERS ID : <br /> I certify under penalty of law that : <br /> 1 . 1 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 and <br /> 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 and/or <br /> imp �isonmentt for known violations . (HSC 25191 ) <br /> Namei- � X 1/1 G /✓ ,v1 (s. c I�� 2�t, L 1 Title : O l I J , <br /> Signature : J2 _ — Date : <br /> CV 411A� <br /> l <br /> 1868 E . Hazelton Avenue Stockton , California 95205 T 209 468-3420 l F 209 464-0138 l www . sjcehd . com <br />