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May.02.2017 10:31 PM Waterloo Liquors 20946 114 PAGE. 1/ 6 <br /> San Joaquin County <br /> Environmental Health Department RECEIVED <br /> 1868 East Hazelton Avenue,Stockton,California 95205-6232 <br /> Telephone.(209)468-3420 Fax:(209)468-3433 Web. -. fehd 3 2017 <br /> RETURN TO COMPLIANCE CERTIFICATIO1111 <br /> %WMONMJ�NyFIV"ITH <br /> Any MINQR violations noted in the"Notice to Comply"in the attached Inspection Report must be 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 ggrreglions to other vjoloQns 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 20 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 no 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/manifeststtraining records/other appropriate paperwork,and/or photos verifying <br /> corrections <br /> Inspection Date: April 04, 2017 Inspected By: CESAR RUVALCABA <br /> Facility Address: 2512E WATERLOO RD, STOCKTON CE IRS ID:-10 181585 <br /> 1 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 /> 1 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: F-OACrN CA&.�- Title: <br /> Signature: Datw. <br /> .......... <br />