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S A N 1 U A p U I N ;f Oi ' D Environmental Health Department <br /> ...,T,� ` Grcorj7css gro:rs hc� UL i 0 2018 <br /> RETURN TO CO LIANCE CERTIFICATION <br /> �pCA � <br /> Any MINOR violations noted in the"Notice omply" 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 /> 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 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 <br /> corrections <br /> Operator's certification <br /> Inspection Date: May 03, 2018 Inspected By: AARON HANG <br /> Facility Address: 9484 WEST LN, STOCKTON CERS ID: 10181655 <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 /> 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 /> J��WTitle:Name: v <br /> Date: <br /> Signature: <br />