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a <br /> 31 <br /> a <br /> Sari Joaquin county <br /> Environmental Health Department <br /> X868 fast Hazelton Avenue , Stoc*ton. Callforn'I'a 95205-6232 <br /> Telephone,o (209) 468-3420 Fix: (2(Q) 468-3433 yYe6: www .si_, oq v.oralehd <br /> RETURN TO COMPLIANCE CERTIFICATION <br /> Any MINER violations noted in the "Notice to Comply" in the attached Inspection Report must be corrected within 30 da s of <br /> receipt of this inspection This certification form must be submitted to the Environmental Health Department (EHD) address at <br /> the top of this dorm wit#yin 30 days of receipt of the Inspection Report HSS 25404. 'i 2(c)( '4 ) <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 da s unless otherwise specified in the <br /> Inspection Report , HSC 25185(c)(3) <br /> Mote : All EHD staff time associated with failing to comply by the above noted dates will be billed <br /> at the current hourly rate . <br /> orth 'i S ct 0 b e complete , the operator of the site must include.- <br /> A <br /> 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 veri �ing corrections <br /> operator's certification <br /> Inspection Dates. June 25 , 2D26 Inspected By: Monica De Anda <br /> Facility Address : 2056 Crestwood Ave CERS ID : 10842625 <br /> I certify under penalty of law that- <br /> I <br /> f have corrected the violations specified in the Inspection Report from the above-mentioned inspection date. <br /> 2 . L have personably examined the following documentation submitted as proof of compliancy FSR EACH VIOLATION and <br /> 1 believe theinformation 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 tnformation, including the possibility of a fine andfor <br /> imprisonment for known vfolations ( HSC 257 91 ) <br />� Name : n rmTitle: �° <br /> Signature ������ Date :.*. <br /> rV <br /> t� <br /> I <br />