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208-02-01 10:49 Safeway 2707 2094728604 >> 2094683433 P 5/6 <br /> San Joaquin County <br /> Environmental Health Department <br /> 1868 East Hacelton Avenue,Stockton,California 95205-6232 <br /> Telephone:(209)468-342.0 Fax:(209)466-3433 Web:www.slguv.oralehd <br /> RETURN TO COMPLIANCE CERTIFICATION <br /> Any MINOR violations noted in the"Notice to Comply"in the attached Inspection leeport must be corrected within 30 days of <br /> receipt of this Inspection, This certification farm must be submitted to the Environmental Health Department(EHD)addross <br /> at the top of this form within 30 days of receipt of the Inspection Report. HSC 2ti404.1.2(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 A hin'90 days unless otherwise specified in thin <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 or sample results/manifestsftraining records/other appropriate paperwork,and/or photos verifying <br /> corrections <br /> Inspection Date: January 18, 2018 Inspected By: ELIANNA H.Oh <br /> Facility Address: 6425 N PACIFIC AVE, STOCKTON CERS ID: 1015681 1 <br /> I certify under penalty of taco that: <br /> 1, 1 have corrected the violations specified in the inspection Report from the abovo-mentioned inspection date. <br /> 2. 1 have personalty examined the following documentation submitted as proof of compliance FOR EACH VIOLATION <br /> and I bolicvo the Information to be true,aM,mile.,and complete: <br /> Photos 1-�'Paporwork ✓ Statement <br /> 3. I 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 /> andfor imprisonment for known violations. (HSC 25191) <br /> Name:{ txal,�r> g �_�,,1 i„-...__ Title: �..z rnar�aa[✓ <br /> Signature:( G Date: <br />