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SAN.PJ AQUIN <br />COUNTY -- <br />Environmental Health Department <br />RETURN TO COMPLIANCE CERTIFICATION <br />Any MINOR violations noted in <br />the "Notice to Comply" <br />in the attached Inspection Report <br />must be corrected <br />within <br />30 days of <br />receipt of this inspection. This <br />certification form must <br />be submitted to the Environmental <br />Health Department (EHD) address at <br />the bottom of this form within 30 days of receipt of the <br />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: <br />Facility Address <br />2110 S Sinclair Ave, Stockton <br />I certify under penalty of law that: <br />Inspected By <br />CERS ID <br />JASON GAITAN <br />10633882 <br />1. I have corrected the violations specified in the Inspection Report from the above-mentioned inspection date. <br />2. I have personally examined the following documentation submitted as proof of compliance FOR EACH VIOLATION and <br />I believe the information to be true, accurate, and complete: <br />Photos Paperwork Statement <br />3. I am authorized to submit this certification on behalf of the Respondent. <br />4. I am aware that there are significant penalties for submitting false information, including the possibility of a fine and/or <br />imprisonment for known violations. (HSC 25191) <br />Name: <br />Title: <br />Signature: Date: <br />1868 E. Hazelton Avenue � Stockton, California 95205 � T 209 468-3420 � F 209 464-0138 I www.sjcehd.com <br />