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SA N 1 Q A OI I I N Environmental Health Departmeii <br /> N U IY � <br /> RETURN TO COMPLIANCE CERTIFICATION .� <br /> 1 <br /> Any MINOR violations noted in the"Notice to Comply"In the attached Inspection Report must ba wrrecletl wiNin 30 days of D <br /> receipt of this inspection.This certification form must be submitted to the Emamamenlal Health Department(EHD)address at <br /> the bottom of this form within 30 days of receipt of the Inspection Report.HSC 25(A.1.2(c)(1) <br /> All corrections to otherviolations acted in the attached Inspection Report(IR)or Continuation Form,or disputes to any m <br /> violations,are to ba submitted using this certification and returned to EHD within 30 days unless otherwise spealied In the L �. <br /> Inspection Report,HSC 251e5(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 resultalmanifests/tmining records/other appropriate papervrork,and/or photos verifying—actions <br /> Operator's certification <br /> �9t <br /> Inspection Date: November 19,2024 Inspected By: KRISTINA SAETERN <br /> Facility Address: 14301 S.ROBERTS RD,STOCKTON CERS ID: 10186361 <br /> 1 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 FACH 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 Respondents_ <br /> 4. 1 am aware that there are significant penalties for submitting false information,including the possibility of a fine andlin <br /> imprisonment for known violations.(HSC 25191) <br /> Name: JOSQ� 7J t t�.f fC — Title. <br /> Signature: ''� <br /> Date. 1�17 L tj <br />