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I ` <br /> Environmental Health Department <br /> ANJOAQUIN <br /> I <br /> 1fl 1% 111Ure <br /> `.1. 1 , <br /> RETURN TO COMPLIANCE CERTIFICATION <br /> Any MINOR violations noted in the "Notice to Comply" in the attached Inspection Report must be corTected 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: June 06 , 2019 Inspected By: SHEWIT WOLDEA,REOAY <br /> Facility Address : 1756 N WILSON WAY , STOCKTON CERS ID: 10180819 <br /> I certify under penalty of law that; <br /> 1e t 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* l 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 <br /> and/or imprisonment for known violations. (HSC 25191 ) <br /> Name: Title: <br /> Signature Date. ' <br /> b$ '�o Z 1 b <br /> 1868 E . Hazelton Avenue 1 Stockton , California 952051 T 209 468-34201 F 209 464-0138 l wwwSicehd . com <br />