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A N ��Q (� Environmental Health Department <br /> Cr; ;ljl1•1 i'Y 4 <br /> RETURN TO COMPLIANCE CERTIFICATION <br /> Any MINQR 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 eorrectionts to other violations noted in the attached Inspection Report(1R)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: May 14 2019 Inspected By: ROBERT LOPEZ <br /> Facility Address: 2402 S CALIFORNIA ST, STOCKTON CERS ID: 10182521 <br /> 1 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. 1 have personally examined the following documentation submitted as proof of compliance FOR EACH VIOLATION <br /> and 1 believe the information to be true, accurate, and complete: <br /> Photos "` Paperwork Statement <br /> 3. I am authorized to submit this certification on behalf of the Respondent. <br /> _4- 1-am aware that there are-sign ificant-penalties_for_submitting-false information, including the possibility_of a fine-- <br /> and/or <br /> ine_and/or imprisonment for known violations. (HSC 25191) <br /> Name: ► �2. rn tel Title: S-'fe�G/ D,,CcC/"e <br /> Signat�e: Date: - <br /> 1868 E, Hazelton Avenue I Stockton, California 952051 T 209 468-34201 F 209 464-0138 1 www.sjcehd.com <br />