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03-30-'19 15:33 FROM- T- P0,001,/0.001 F-,' <br /> I San Joaquin County D <br /> Environmental Health Department JUN 19 2017 <br /> 1868 East Hazelton Avenue, Stockton, California 95205-6232 <br /> Telephone,(209)468-3420 Fax.(209)468-3433 Web.-www,sjgov.oro/ehd <br /> vl iV&iONMENTAL HEALTH <br /> RETURN TO COMPLIANCE CERTIFICATION DEPARTMENT <br /> Any MINOR N iolations noted in the"Notice to Comply"in the attached Inspection Report must be corrected within 30 dates of <br /> receipt of this inspection. This certification form must be submitted to the Environmental Health Department(EHD)address <br /> at the top of t iis form within 30 days of receipt of the Inspection Report HSC 25404.1.2(c)(1) <br /> All correction her violations noted in the attached Inspection Report(IR)or Continuation Form,or disputes to any <br /> violations, ar to be submitted using this certification and returned to EHd within 30 days unless otherwise specified in the <br /> Inspection RE port. HSC 25185(c)(3) <br /> Note: All HD staff time associated with failing to comply by the above noted dates will be <br /> bille d at the current hourly rate. <br /> For this ertification to be complete, the operator of the site must include: <br /> A sta ement documenting what corrective actions were taken or will betaken for each violation <br /> Copies of sample results/manifests/training records/other appropriate paperwork,and/or photos verifying corrections <br /> Inspectio Date: May 22, 2017 inspected By: VICKI MCCARTNEY <br /> Facility Address: 749 E DR MARTIN LUTHER KIND JR BLVD, CERS ID: 10181497 <br /> I certify under penalty of law that: <br /> 1. I ham corrected the violations specified in the Inspection Report from the above-mentioned inspection date <br /> 2. 1 hay 3 personalty examined the following documentation submitted as proof of compliance FOR EACH VIOLATION <br /> and I lieve the information to be true, accurate,and complete: <br /> Photos Paperwork_a_Statement <br /> 3. I am 3uthorLzed 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 and/ <br /> impri onment for known violations. (HSC 25191) <br /> Name: yw��w� Title: <br /> Signatu e: � r Date: (e <br /> V\ Ce' . <br /> oZ — 4��Z2 1u \S _�CITL' o�efl <br /> W� btu '�sx aver-. -ryc'_ Com�uTe� l,aa�-� o�a2� <br /> PR0a3 1c��� FAova38�o <br />