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SAN JOAQUIN COUNTY 0 10 <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />600 East Main Street, Stockton, CA 95202-3029 <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sogov.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 Inspection Report (IR) or Continuation Form, or <br />disputes to any violations, are to be submitted using this certification and returned to EHD within 30 days <br />.- `he '£ed the inspection HSC <br />2511 C)5 i3y <br />=:�r L ii %vi 5}1e3ic9 �a in €��� i::at�e tii7n i'sfltirt. �L� ;*a.)( )(0 <br />atE:; € EHD staff time associat d With failing to compl the above Noted dates W,.,! he <br />himed al the cur.- -Urn hourly <br />Tf- <br />�' .� c <br />i w U 110 *_ toa a I%� iia. a a .S.i it .i4 1 i1 vs `z%c arc aiv� 4 � 'ac w = `sniti ; <br />- <br />inspection Date: May 1, 2012 Inspected y:Aris Cacapit <br />a d -_---- <br />F acilitj .�:��;r::r�. 5 _ Ammer Lane <br />I certify under penalty of law that: <br />-- I=PA %.i#. <br />1. 1 have corrected the violations specified in the Inspection Report from the above-mentioned <br />inspection date. <br />2. 1 have personally examined the following documentation submitted as proof of compliance FOR <br />EACH VIOLATION and I believe the information to be true, accurate, and complete: <br />Photos Paperwork Statement <br />3. 1 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 <br />possibili"a fine and/or imprisonmP,.Qt for known violations. (HSC 25191) <br />Name: <br />Signature: <br />EHD 22-02-005 Rev 09/11 <br />Title- <br />/ �--� Date: <br />