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SAN J O A Q U I N Environmental Health Department <br /> C(.).i 'A"l-_Y <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(IR)or Continuation Form, or disputes to any <br /> violations, are to be submitted using this certification and returned to EHD within 30 days unless otherwise specified 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 /> 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 records/other appropriate paperwork, and/or photos verifying <br /> corrections <br /> Operator's certification <br /> Inspection Date: December 05, 2018 Inspected By: CESAR RLJVA1 (-AR` <br /> Facility Address: 3003 NAVY DR, STOCKTON CERS ID: 10182187 <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 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 /> XPho[os X PaperworkStatement <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 violations (HSC 25191) <br /> Name: ) V1 ��� Title: 7-r S <br /> Signature: / G — Date: <br /> r <br /> 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209464-0138 1 www.sjcehd-com <br />