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SAN MUM Environmental Health Department <br /> LOU NY <br /> Greatness groove herr. <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 ofthis form within 30 days of receipt of the Inspection Report. HSC 25404.1.2(cx1) <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(cx3) <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 recordsrother appropriate paperwork,and/or photos verifying <br /> corrections <br /> Operator's certification <br /> Inspection Date: October 08, 2018 Inspected By: CESAR RUVALCABA <br /> Facility Address: 16401 E HWY 26 , LINDEN CERS ID: 10396426 <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 I believe the information to be true,accurate,and complete: X <br /> Photos Paperwork X Statement <br /> 3. lam authorized to submit this certification on behalf of the Respondent. <br /> 4. lam 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: Sam B. Robinson _____Title:_ Safety/Compliance Officer <br /> Signature:_ ' ' _______Date: _ 11/05/2018 <br /> 1868 E. Hazelton Avenue I Stockton,California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjcehc eom <br />