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Sh O h n ( � Environmental Health Departmeno: <br /> N N t! Izl l'� l l� zt3 <br /> C O U ISI 1 Y <br /> RETURN 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 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 <br /> billed 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 <br /> corrections <br /> Operator's certification <br /> Inspection Date : December 11 , 2018 Inspected By : ZUNA BARKER <br /> i <br /> Facility Address : 3032 E WATERLOO RD , STOCKTON CERS ID : 10180877 <br /> F <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 : Title : <br /> I <br /> Signature : Date : <br /> 1868 E . Hazelton Avenue I Stockton , California 95205 I T 209 468-3420 I F 209 464-0138 1 www, sjcehd . com <br />