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oocTON,CA 95204 CAL000402455 <br /> ON <br /> Joaquin -- - ------- <br /> Status <br /> a Draft submittal as of 11/3/1017,Last updated by GHULAM AL1 on 11/3/2017 2-57 <br /> Matatir� <br /> San Joaquin County <br /> Environmental Health Department <br /> 1868 East Hazelton Avenue, Stockton, California 95205-6232 <br /> Telephone:(209)468-3420 Fax:(209)468-3433 Web: <br /> www siaoy.ora/ehd <br /> RETURN TO COMPLIANCE CERTIFICATION <br /> Any MINOR violations noted in the"Notice to Comply"in the attached Inspection Report must be corrected.+wit►,tr,30 days of <br /> receipt of this inspection. This certification f rt form must be submitted to the <br /> the Inspection Report. HSC nviron ental(Health Department(EHD)address <br /> the top of this form within 30 days <br /> on Form, or disputes to <br /> All corrections to other violations notedthis certification and retumedd Inspection Ro EHD within`!$ueport(IR)or lnless otherwise specified in the <br /> violations, are to be submitted using <br /> Inspection Report. HSC 25185(c)(3) <br /> Note. <br /> 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 <br /> eoperator of the il betakenmust include: <br /> for each violation <br /> A statement documenting what co taken or nate paperwork, and/vi photos verifying corrections <br /> • Copies of sample results/manifests/training records/other appropriate STACY RIVERA <br /> Inspected By: <br /> Inspection Date: Februa 28, 2018 CERS ID: 10181239 <br /> Facility Address: 16 E HARDING WAY, STOCKTON <br /> 1 certify under penalty of law that: <br /> 1. 1 have corrected the violations specified in the Inspection Report from the above-mentioned <br /> compliance FOR EACH VIOLATION <br /> 2. 1 have personally examined the following documentation submitted as proof of c p <br /> 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 Respondent. <br /> 4. 1 am aware that there are significant penaltHSC ties for <br /> submitting false information, including the possibility of a fine and/ <br /> imprisonment for known violations. ( <br /> 6/l w j ��t Title: <br /> Name: <br /> Date <br /> Signature: <br />