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T,-,wSAN <br />ENVIRO MENTAUL�HEALTHQUIN ODNPARTMENT <br />1868 East Hazelton Avenue, Stockton, Kalifornia 95205-6232 <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.siclov.org/ehd <br />RETURN TO COMPLIANCE! CERTIFICATION <br />Any MINOR violations noted in the "Notice to Comply" in the attached Inspection Report must be <br />corrected within 30 days of receipt of this inspection. This certification form must be submitted to the <br />Environmental Health Department (EHD) address at the top of this form within 30 days of receipt of the <br />Inspection Report. HSC 25404.1.2(c)(1) <br />All corrections to other violations noted in the attached Insper'tion Report (IR) or Continuation Form, or <br />disputes to any violations, are to be submitted using thisertification and returned to EHD within 30 days <br />unless otherwise specified in the Inspection Report. HSQ¢25;185(c)(3) <br />Note: All EHD staff time associated with failing t� comply by the above noted dates will be <br />billed at the current hourly rate. <br />For this certification to be completethe operator of the site must include: <br />• A statement documenting what corrective actions were laken or will be taken for each violation <br />• Copies of sample results/manifests/training records/other appropriate paperwork, and/or photos <br />verifying corrections <br />• Operator's certification <br />Inspection Date: 30 <br />Facility Address: " ! 07-7 L , %'� Y- , jt/ <br />I certify under penalty of law that: <br />1. 1 have corrected the violations specified in the In <br />inspection date. <br />2. 1 have personally examined the following docum <br />EACH VIOLATION and I believe the information <br />Photos Pa <br />3. 1 am authorized to submit this certification on bE <br />4. 1 am aware that there are significant penalties for <br />possibility of a fine and/or imprisonment for know <br />Name: 6/1"F6�r <br />Siqnature: <br />EHD 22-02-005 Rev 04/19112 <br />Inspected By: Stacy Riven <br />AID#: <br />on Report from the above-mentioned <br />on submitted as proof of compliance FOR <br />true, accurate, and complete: <br />rk Statement <br />f the Respondent. <br />u4mitting false information, including the! <br />violations. (HSC 25191) <br />Title: <br />Date: <br />