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San Joaquin County <br /> Environmental Health Department <br /> 1868 East Hazelton Avenue, Stockton, California 95205-6232 <br /> Telep one: (209)468-3420 Fax: (209) 468-3433 Web:www.sjgov.or,/g ehd <br /> RE URN 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 of this form within 30 days of receipt of the Inspection Report. HSC 25404.1.2(c)(1) <br /> All corrections to other violatio s noted in the attached Inspection Report (IR) or Continuation Form, or disputes to any <br /> violations, are to be submitted sing this certification and returned to EHD within 30 days unless otherwise specified in the <br /> Inspection Report. HSC 2518 (c)(3) <br /> Note: All EHD staff time associated with failing to comply by the above noted dates will be <br /> billed at the curre t hourly rate. <br /> For this certificatio to be complete, the operator of the site must include: <br /> A statement documents g what corrective actions were taken or will be taken for each violation <br /> Copies of sample resul s/manifests/training records/other appropriate paperwork, and/or photos verifying <br /> corrections <br /> Operator's certification <br /> Inspection Date: Augusl 26, 2016 Inspected By: Michelle Henry <br /> Facility Address: 1640 Broadway Ave CERS ID: 10685554 <br /> 1 certify under penalty of law tha : <br /> 1. I have corrected the viol tions specified in the Inspection Report from the above-mentioned inspection date. <br /> 2. 1 have personally exam ned the following documentation submitted as proof of compliance FOR EACH VIOLATION <br /> and I believe the inform tion to be true, accurate, and complete: <br /> Photos Paperwork Statement <br /> 3. 1 am authorized to sub it this certification on behalf of the Respondent. <br /> 4. 1 am aware that there a e significant penalties for submitting false information, including the possibility of a fine <br /> and/or imprisonment for known violations. (HSC 25191) <br /> Name: Title: <br /> Signature: Date: <br />