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SAN JOAOUIN Environmental Health Department <br />RETURN TO COMPLIANCE CERTIFICATION <br />Any MINOR violations noted in the Notice to Comply' in the attached Inspection Report roust be. = meed with,, 30 days of <br />recegt of this inspection This certification form must be submitted to the Environmental Health Department (EHD) address at <br />the bottom of this form within 30 days of receipt of the Inspection Report. HSC 25404.1.2(cx1) <br />All corrections to other- t noted in the attached Inspection Report (IR) or Continuation Form. or Asputes to any <br />violations, are to be submitted using this certification and retumcc to EHD withm 30 days unless otherwise specified in the <br />Inspection Report. HSC 25185(c)13) <br />Note: All END 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 mustinc[uoc <br />A statement documenting what Corrective actions were takm w will be la ken for each violator <br />Copies Of sample resullslmanifeaWtntining recormlothef appropriate paperwork. and/or pholm verifying corrections <br />- Operator's certification <br />Inspection Date: September 09, 2019 Inspected By: CESAR RUVALCABA <br />Facility Address: 14210 W HWY 4, STOCKTON CERS ID: 10185713 <br />I certify under pe ullty of law thub <br />1. I have corrected the violations specified in the Inspection Report from the abovo-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 />_ __PhotosPaperwork ✓_Statement <br />3. lam authorized to submit this cenficahm On behalf of the Respondent. <br />C lam aware that there are significant penalties for submitting false information, including the possibility of s fine and( <br />imprisonment for known vi lab .. (NSC 25191) <br />Name: f I Title -/f <br />Date: <br />Signatu <br />