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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1868 East Hazelton Avenue,Stockton,California 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 Inspection Report(IR) or CorLinuation Form, or <br /> disputes to any violations, are to be submitted using this certification and returned to D within 30 days <br /> unless otherwise specified in the Inspection Report. HSC 25185(c)(3) <br /> Note: All EHD staff time associated with failing to comply by the P fled dates will be <br /> billed at the current hourly rate. <br /> For this certification to be complete the o rasite must include: <br /> • A statement documenting what corrective actions were to a taken for each violation <br /> • Copies of sample results/manifests/training records/ r fate paperwork, and/or photos <br /> verifying corrections <br /> • Operator's certification <br /> Inspection Date: February 4, 2020 Inspected By:Lydia Baker <br /> Facility Address:2403 W LOUISE A EPA ID#: CAR000298380 <br /> I certify under penalty of law <br /> 1, 1 have corrected the la specified in the Inspection Report from the above-mentioned <br /> inspection date. <br /> 2. 1 have perso mined the following documentation submitted as proof of compliance FOR <br /> EACH VI TI and I believe the information to be true, accurate, and complete: <br /> Photos Paperwork _Statement <br /> 3. 1 am thorized 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 /> possibility of a fine and/or imprisonment for known violations. (HSC 25191) <br /> Name: le: � n+,O fl o Qef(Lo m M N Rge <br /> Signature: Date: S L UZO <br /> EHD 22-02-005 Rev 04/19/12 <br />