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[� nvorrol� ir� er� ta .� Rall ..e r <br /> i <br /> . F 1: 1 J. 2019 <br /> r firrrlt �iPSS c; r » rv5 1rr , <br /> RETURN TO COMPLIANCE CERT' IFIC T r ; NML:.: NTk\ l _ HL.ALYH <br /> DEf'AR1• i" 1� 1 <br /> Any MINOR violations noted In the " Notice • to Comply" in the attached Inspection Report must be corrected within 30 days of i <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 2640401 ,2(c) ( 1 ) j <br /> I <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 END within 30 dates 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 : January 15 , 2019 Inspected By: GARRETT BACKUS <br /> Facility Address : 7910 S LONGE , STOCKTON CERS ID: 10184277 <br /> 1 certify under penalty of law that: <br /> 1 . 1 have corrected the violations specified in the Inspection Report from the above -mentioned inspection date. i <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 /> i <br /> Photos Paperwork Statement r <br /> 3 . 1 am authorized to submit this certification on behalf of the Respondent. <br /> 40 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 : CK(LZS `�ay.UL� Title: I vvstt0 + !5A60`�/ MAAAerxjc T <br /> Signature: Date: T- Ifo$ let <br /> I <br /> i <br /> 1868 E , Hazelton Avenue l Stockton , California 95205 l T 209 468-3420 F 209 464-0138 l www, Sicehd.com <br />