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Environmental Health Department <br />RETURN Tb COMPLIANCE CERTIFICATION <br />Any MINOR violations noted in th® "Notice to Comply" In the attached Inspection Report must be corrected within 30 daA of <br />receipt of this Inspection. This certification form must be submitted to the Environmental Health Department (EHD) address at <br />the bottom of this form within 30 days of receipt of the Inspection Report, HSC 25404.1.2(c)(1) ' <br />All corrections tQ�ther violations nosed in th6 attached Inspection Report (IR) or Continuation Form, or disputes to any <br />violations, aro to be submitted using this certification and returned to EHD Athin 30 days unless otherwise specified in the <br />Inspeotlon Report. H8C 25185(c)(3) <br />Note: All EHD staff time associated with failing to comply by the above notedYlates will be It <br />billed at <br />the current hourly rate. <br />For this certifrcatian to bt? 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 corrections <br />Operator's certification <br />Inspection Date; April 30, 209_ Inspected By; NICHOLAS LQEHRER <br />Faculty Address; 336 E MAIN ST, RIPON CERS ID: 10788886 <br />I certify under penalty of law that: <br />1- I 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 EACH VIOLATION <br />end 1 believe the Information to be ttue, accurate, and complete. <br />l� Photos ✓� Paperwork Statement <br />3. I am authorized to submit this certification on behalf of the Respondent. <br />4. I 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:�v� � 9 Title: ",6., <br />Signature: AJ t N i� r2 L)L"7�. V\ Date: 9 <br />REECEIVED <br />Eta`"fAC• HE A <br />!)!? Pfd `t�t C6�'"t' <br />1868 E. Hazelton Avenue I Stockton, California 95205 I T 209 4683420 I F 209 464-0138 I www,sJeehd.com <br />Received Time Jun. 6, 2019 11:55AM No. 5096 <br />s. <br />