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Environmental Health Department <br /> COUNTY <br /> RETURN N T MPLI NCE CERTIFICATION <br /> Any MINORâ–ºriafalions noted in the"Notice to Comp IV' In the attached Inspection Report must be corrected within0 dys of <br /> receipt of this inspectlon. This certification form must be submitted to the Environmontal Health Department(EHD) address at <br /> the bottom of this form within 30 days of receipt of the Inspection Report. HSC 5404.1. (c)(I) <br /> AllpQrrectophs to other violations noted in the attached Inspaollon Report(IR) or Continuatlon Form, or disputes to any <br /> violations, are to he submitted using this certification and returned to EHP Within 34 days unlass otherwise specified in the <br /> Inspection Report- HSG 25185(c)(3) <br /> Note: All EHD staff time associated with failing to comply by the above noted dates will be <br /> bilie d at the current hourly rate. <br /> For this certification to be complete, the operator of the site must include: <br /> A statement documenting what correOve actions were taken or will be taken for each violation <br /> Copies of sample results knanifestsftralning recordsiother appropriate paperwork, and/or photos verifying corrections <br /> Operator's cartitication <br /> Inspection Date: September 01, 2020 Inspected By: ROBERT LOPE <br /> Facility Address: 6471 Pacific Ave, Stockton CERS ID: 10144066 <br /> certify under penalty of law that: <br /> 1. 1 heve corrected the violations speclfAd in the lnspec6ion Report from the above-mentioned inspection date, <br /> 2. 1 have personally examined the follo Ang d!ocumentstion submitted as proof of compliance FOR EACH VIOLATION <br /> and I belilove the infoTmation to be true, accurate, and complete: <br /> Photos Paperwork Statement <br /> 3, 1 ern authorised 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 andh <br /> imprisonment for known violations- (HSG 25191) <br /> Name: AftmwW Dftw° r"'�0,,W. Title-. <br /> Signatur Date: <br />