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�6D'°N WdLZ:� 8lOZ '�l 'AON ;11111 pan1a;;� <br />SA W) OA 0 U I N <br />Environmental Health Department <br />j Ij r .Y ... <br />RETURN TO COMPLIANCE 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 <br />at the top 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 recordslother appropriate paperwork, and/or photos verifying <br />corrections <br />Operator's certification <br />Inspection Date: November 06, 2018 <br />Facility Address: 140 E LATHROP RD, LATHROP <br />I certify under penalty of law that: <br />Inspected By: NICHOLAS LOEHRER <br />CERS ID: 10182153 <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 <br />and I believa the information to be true, accurate, and complete: <br />Photos Paperwork Statement <br />3. 1 am autho ized 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 <br />and/or impri onment for known violations, (HSC 25191) <br />Name; L Title: )�'%✓Z�— <br />Signature:_ 9 �___.._. _ Date: <br />RECD:. <br />NOV 1 3 2018 <br />ENVIRONMEN-AL HEALTH <br />r)FFr49T^AENT <br />1868 E. Hazelton Avenue 1 Stockton, California 952051 T 209 468-3420 1 F 209 464-0138 1 www.sjcehd.com <br />I• abed xed dH Z5191• 81.0Z <br />