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A"= law% <br /> R E <br /> San Joaquin County <br /> Environmental Health Department <br /> 1868 East Hazelton Avenue, Stockton, California 95205-6232NVI RON A4 ENTAL H EALTH <br /> Telephone. (209)468-3420 Fax:(209)468-3433 Web:m8ffi&Wa1-1Y--org1s—he E:PARTM ENT <br /> RETURN TO COMPLIANCE CERTIFICATION <br /> ny MIORviolations noted in the"Notice to Comply" in the attached Inspection Report must be corrected within des of <br /> meipt of this inspection. This certification form must be submitted to the Environmental Health Department(EHD)address <br /> t the top of this form within 30 days of receipt of the Inspection Report. HSC 25404.1.2(c)(1) <br /> 11 corrections to other violations noted in the attached Inspection Report(IR)or Continuation Form,or disputes to any <br /> olations, are to be submitted using this certification and returned to EHD within 30 days unless otherwise specified in the <br /> ispection Report. HSC 25185(c)(3) �L <br /> tote: All EHD Staff time associated with failing to comply by the above noted dates will be <br /> billed at the current hourly rate. <br /> "or 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 /> nspection Date: November 30, 2017 Inspected By: John Alaniz <br /> "acility Address: 15 E GRANT LINE RD CERS ID: 10181019 <br /> ertify 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. <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 /> Y <br /> Title; -f'eore4Y <br /> Y-e- <br /> Name: sr <br /> Date: re <br /> Signature: — --------------- <br /> 23i 4C4 <br /> 91719690 0935 0152 1703 51 <br />