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10/06/2011 08 :04 2099316743 Waterloo Food hart 40720 P. 002/015 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 600 East Main Street,Stockton,CA 95202-3029 <br /> Telephone:(209)468-3420 Fax:(209)458-3433 Web:www.si4ov.orglehd <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 days of receipt of this inspection. This certification form must be submitted to the <br /> Environmental Health Department(EHD)address at the top of this foram within 30 days of receipt of the <br /> Inspection Report. HSC 25404.1.2(c)(1) <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 days <br /> unless otherwise specified in the Inspection Report. HSC 25185(c)(3) <br /> Note: All END staff time associated with failing to comply by the above noted dates will be <br /> billed at the current hourly rate. <br /> r._+r phis �^,-{.�ca�tia» �v l:rsr c..v��rNrvly ttw v'.vcitvi ..r uc�tw �nuol uii,tuUc. <br /> Copica of nnmplt maulta/manifcata/tlell lilIg fel,r.1rcla/cltter appropriate paperwork, and/or photon <br /> verifying corrections <br /> • Operator's certification <br /> Inspection Date: October 4, 2011 Inspected By:Garrett Backus <br /> roo;Ji y Addl��: 7316 E W'Qt'=rlo.-, r2.tcid crq iro#. OAL000340107 <br /> 9_ I have corrected the violations sReciGud in the Inspection Report from the albove-mentioned <br /> incpootion dote. <br /> ?_ 1 hove peroenally ex®minod tho folivwiy Jv�:u�iic:�ilrrLivii �ulntti[Ecc1 tri pruvf Ur complldrlGe FVK <br /> EACH VIOLATION and I believe the informtion to be true, accurate, and complete: <br /> Photos ",/Paperwork ✓/Statement <br /> J <br /> 3. 1 am4bilif <br /> d to submit this certification on behalf of the Respondent. <br /> 4. 1 amat there are significant pe its for submitting false information, including the <br /> posa fine and/or imp ' ent for known violations. (HSC 25191) <br /> Name: <br /> Title: " <br /> Signature: .i � d�. Date: <br /> EHD 22-02-005 Rev 09/11 <br />