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Vaf: 1/LV iu 11A( IZVy�1412226 Country Marketplace tt3841 P. 002/004 <br /> Environmental Health Department <br /> EIVED <br /> Ive <br /> RETURN TO COMPLIANCE CERTIFICATION JUN 21 2018 <br /> Any MINOR violations noted in the"Notice to Comply'in the attached Inspection Report must be cone ted within 30 ays 40NMENTAL <br /> receipt of this inspection- This certification form must be submitted to the Environmental Health Department(EHD)address APITM NT <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 violati4l noted in the attached Inspection Report(IR)or Continuation Form,or disputes to any <br /> violations,are to be submitted using this certification and retumed to EHD within 0 da s unless otherwise"cified 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 /> bilied at the current hourly rate. <br /> For this certif cation 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 resultslmanifests/training records/other appropriate paperwork,and/or photos verifying <br /> corrections <br /> Operator's Certification <br /> Inspection Date: March 27, 2018 Inspected By: CESAR RUVALCABA <br /> Facility Address: 1739 W CHARTER WAY, STOCKTON CERS IU: 10182247 <br /> I certify under penalty of law that <br /> 1. 1 have corrected the violations specified in the inspection Report from the above-mentioned inspection date- <br /> 2. I have personally examined the following documentation submitted as proof of compliance FOR FACH VIOLATION <br /> and I believe the information to be true,accurate,and complete: <br /> PhotosTTTpaperwork Statement <br /> 3. I 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 violations. (HSC 25191) <br /> Name: <br /> Signature-- Date' a / <br /> �°� (. f 2 01?-- A//III poe6 &)-1 149 <br /> 1868 E.Hazelton Avenue; St ekton,California 852051 T 209468-S4201 F 209464-0128 j www,sicehd.com <br /> rh-A x <br />