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SAN JUAQUIN <br />J j ]T; <br />Environmental Health Department <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. HSG 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 <br />corrections <br />Operator's certification <br />Inspection Date: May 31, 2018 Inspected By: NICHOLAS LOEHRER <br />Facility Address: 1000 E ROTH RD, FRENCH CAMP CERS ID: 10183327 <br />I certify under penalty of law that: <br />1. I have corrected the violations specified in the Inspection Report from the above-mentioned inspection date. <br />2. I have personally examined the following documentation submitt <br />Photos �Papenvork X <br />! <br />ed <br />as proof of <br />compliance FOR EACH VIOLATION <br />and I believe the information <br />to be true, accurate, and complete: <br />Statement <br />3. I am authorized to submit this certification on behalf of the Respondent. <br />4. I am aware that there are significant penalties for submitt <br />ing false information, including the possibility of a tine <br />and/orim u�sonmentforknownviolations. (HSC 25191) � / <br />Name: &*1M0 6gvtypt Title: 1 �'y/�'�?G�L(t417I Ffeldl �/t3�%`OV5 <br />Signature: �{p� t A Date: (`�(n A2, /018 <br />1868 E. Hazelton Avenue � Stockton, California 95205 I T 209 468-3420 � F 209 464-0138 � www.sjcehd.com <br />