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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.sjgov.orcl/ehd <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 <br />days of receipt of this inspection. This certification form must be submitted to the Environmental Health Department <br />(EHD) address 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 <br />any violations, are to be submitted using this certification and returned to EHD within 30 days unless otherwise <br />specified in the Inspection Report, HSC 25185(c)(3) <br />Note: All EHD staff time associated with failing to comply by the above noted dates will be billet <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 <br />Inspection Date <br />Fac <br />ility Address: <br />July 16, 2018 <br />1176 STANISLAUS ST <br />I <br />P <br />certify under penalty of law that: <br />Inspected By: <br />CERS ID: <br />Cesar Ruvalcaba <br />10181451 <br />1. I have corrected the violations specified in the Inspection Report from the above-mentioned inspection date. <br />2. I have personally examined the following documentation submitted as proof of compliance FOR EACH <br />VIOLATION and I believe the information to be true, accurate, and complete: <br />Photos aperwork Statement <br />3. I am authorized to submit this certification on behalf of the Respondent. <br />4. I am aware that there are significant penalties for submitting false information, including the possibility of a <br />fine and/or imprisonment for known violations. (HSC 25191) <br />Name: <br />Title: � i�E�jyIZ O{� IN j < <br />E�IVI(-�ONNIENTAL HEALTH <br />PEf1MIT/SERVICES <br />