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San Joaquin bounty <br />rHnvironmental Health Department <br />1868 East Hazelton Avenue, Stockton, CaSifornla 95205-6232 <br />Telephone; (209) 468-3420 rax: (209) 468-3433 Web' www.siqoV.orc�shd <br />RETURN TO COMPLIANCE CERTIFICATION <br />Any MINOR violations noted in the'Nutics to Camply' In the attached Inspection Report must be corrected wMlhin 30 days of <br />receipt of Ihls inspeckion. This certification form must be submitted to the Environmental Health Dap&r rmrd (EHD) address at <br />the top of this form within 30 days Qf n3mApt of the Inspection Reporl- HSC 25404,1,2(c)(1) <br />All currectiorns to other violations noted in the attached Inspection Report (IR} or Conl5nuation Form, or disputes to any <br />vMatlons, are to be submitted using this certtFcaton and returned to EHD +within 30 dayp unless othorwise spedfod In the <br />Inspection Report_ H SC 251 B5(c)(3) <br />Note: All E H D staff time associated with falling to comply by the above noted dates will be billed <br />at the current hourly rate. <br />1= ort th Is Certificatio n to be com plete, the operator of the site must Include: <br />A statemept documenting what carractive actions were taken or will be taken for each violation <br />Copies of sample Fesultslmart Ifesishraining recordslakher appropriate paperwork, andl❑r photos verifying caorrectlons <br />Operator's certincatian <br />Inspection lute: <br />FaOI4 Address: <br />July 22, 2D24 <br />4011 E MORADA LN all* 110 <br />I certify under penalty of law that <br />Inspected By: Maria Lopez <br />CERS ID: lDG50247 <br />1, 1 have carrected the violations specified in the Inspection Report from the agave -mentioned inspectlon date. <br />2. 1 have personally examined the fallowing docurnentakion submitted as proof of compliance FOR EACH VIOLATION and <br />I believe tha infonmalion to be true, accurate, and compute. <br />3Photos X Papenvofk _ataWment <br />3. I am authodaed to submit this e,a'rrtificakn on behalf of the Respondent. <br />4, t am aware that there are significant penal#les for submitfing False Information. Including the possibility of a fine ar0or <br />imprisonment for known violations. (HSC 25191) <br />Name: I`-'1 � 1 1�'i Title: l � <br />Signature'— Date. l ` C) V <br />