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03/14/2019 05:18,.;._-_:�,._, _ <br /> Cool <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 600 East Main Street, Stockton, CA 95202-3028 <br /> Telephone:(209)468-3420 Fax:(209)466-3433 Web:www_§' ov.or /ehd <br /> RETURN TO COMPLIANCE CERTIFICATION <br /> Any MINOR violations noted in the"Notice to Comply" in the attached Inspection Report must be <br /> corrected within 30 dans of receipt of this inspection. This certification form must be submitted to the <br /> Environmental Health Department(EHD) address at the tap of this form within 30 days of receipt of the <br /> Inspection Report <br /> All corrections to other violations noted in the attached Inspection Report(IR) or Continuation Form, or <br /> disputes to any violations, are to be submitted using this certification and returned to EHD within 30 dans <br /> unless otherwise specked in the Inspection Report. <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 /> I� Or this certification t0 be complete the operator of the site must include: <br /> ( e A statement documenting what corrective actions were taken or will be taken for each violation <br /> a Copies of sample results/menifests/training recordsiother appropriate paperwork, and/or photos <br /> iverifying corrections <br /> a Operator's certification <br /> Inspection Date: 1� 2 I r? 11 Inspected By: <br /> Facility Address:] "�� <br /> Cly , <br /> I certify under penalty of law that: <br /> 1. 1 have corrected the violations specked in the Inspection Report from the above-mentioned <br /> inspection date. <br /> 2. 1 have personally examined the following documentation submitted as proof of compliance FOR <br /> EACH VIOLATION 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. <br /> espondent4. 1 am aware that there are significant penalties for submitting false information, including the <br /> possibility of a fine and/or imprisonment for known violations. (HSC 25191) <br /> Name: Title: t _ t�(�trlCh <br /> x'•20 • � . - <br /> Signature: r r V _� ,ti• <. -- e: <br /> i <br /> EHD 22-02405 Re„1=9 <br />