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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:www.sjcaov.erg/ehd <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 (1R) or Continuation Form, or disputes to any <br /> violations, are to be submitted using this certification and returned to FH❑within 30 days unless otherwise specified in the <br /> Inspection Report. FISC 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 recordsiother appropriate paperwork, and/or photos verifying <br /> corrections <br /> Operator's certification <br /> Inspection Date: September 18, 2017 Inspected By: Betty Ho <br /> Facility Address: 5655 Hood Way CERS ID: 10689070 <br /> 1 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. 1 have personally examined the following documentation submitted as proof of compliance FOR EACH VIOLATION <br /> and 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 penalties for submitting false information, including the possibility of a fine <br /> and/or imprisonment for known Volations, (HSC 25191) <br /> Mame: .=Lp `J(0� C-� m Title: S4. C_ny. ( t;C"exu :S�: Cia- ,S' <br /> Signature: Date: - 1� <br /> FES 2018 <br /> ENVIRONMENTAL HEALTH <br /> 1117,PA,RTMENT 9171 9690 0935 0151 6829 85 <br />