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07-15-' 19 14012 FROM- 12094626171 T-022 P0001 /0002 F-071 <br /> Environmental Health Department <br /> SAN 40 <br /> ac ... <br /> COYNT <br /> RETURN TO COMPLIANCE CERTIFICATION <br /> Any MINOR violations noted in the "Notice to Compir 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 : May 31, 2019 Inspected Sy : STACY RIVERA <br /> Facility Address : 749 E DR MARTIN LUTHER KING JR BLVD , CERS ID : 10181497 <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 7VIOILAATION <br /> 2 . 1 have personally examined the following documentation submitted as proof of compliance FOR EACH <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 : a=L <br /> Title: b XtQ &,Uq <br /> Signature : 2 <br /> Ix LLJ Ci it V <br /> JUL 19 202 <br /> LNVIRONi\ IENTAL I ( EAffll <br /> DEPAR"TNILN "T <br /> 1868 E . Hazelton Avenue 1 Stockton , California 95205 I T 209 4683420 1 F 209 464-0138 1 wvvw.sjcehd. com <br /> Received Time Ju1 . 15 . 2019 211OPM No , 5261 <br />