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f ~ Q I nvlrprimentAl Health Department <br /> SAN G. <br /> r '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 /> 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 <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 corrections <br /> Operator's certification <br /> Inspection Date: August-06 "'2 • Inspected By: JASON GAITAN <br /> Facility Address : 819 E FREMONT ST, STOCKTON CERS ID: 0 <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 /> 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 and/ <br /> imprisonment for known /violations. (HSC 25191 ) <br /> Name: S7D , ) GL �/ rutie1nbte L/ Az— Title: bp6 LC f�✓ <br /> Signature: S471A. V Date: 611 fl ®/ <br /> 1868 E . Hazelton Avenue I Stockton , California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjcehd. com <br />