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Env ngental Health Department <br /> SANsJOAQUIN <br /> I : E <br /> I a Tl � IVSD <br /> - '�,�t � ft' f/ lJ7QS5 � rc71'L`, �tr' Je . JAN <br /> 2 4 2020 <br /> RETURN TO COMPLIANCBGERTJR9A ..T <br /> TH <br /> PERMIT/ SERVICES <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 at <br /> the bottom of this form within 30 days of receipt of the 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 disputes to any <br /> violations , are to be submitted using this certification and returned to EHD within 30 days 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 billed <br /> 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 corrections <br /> Operator' s certification <br /> Inspection Date : October 28 , 2019 Inspected By : LYDIA BAKER <br /> Facility Address : 820 N UNION ST , STOCKTON CERS ID : <br /> I certify under penalty of law that: <br /> 1 . 1 have corrected the violations specified in the Inspection Report from the above- mentioned inspection date . <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 /> 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 possibility of a fine <br /> and/or imprisonment for known violations . ( HSC 25191 ) <br /> Name : JJan IS a vic, eZ GeV✓ Title: C0 - pWv%.d %1 <br /> Signature : Date: <br />