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, r <br /> 1•<i���r, {; A An Environmental Health Department <br /> lot <br /> COUNTY <br /> t •5l.r,.c,:+ '`•• ti!' �` l� itYQ <. � tlrtYrvS Iran. <br /> RETURN TO COMPLIANCE CERTIFICATION <br /> Any MINOR violations noted In the "Notice to Comply" 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)(f ) <br /> All corrections to other Volatfons 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 daVa unless otherwise specified in the <br /> Inspection Report. HSC 25185(c)(3) <br /> Note: All EHD staff time associated with falling to comply by the above noted dates will be <br /> billed at the current hourly rate. <br /> i <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 /> Operators certification <br /> Inspection Date . July 01 , 2019 Inspected By. SHEWIT WOLDEAREGAY <br /> Facility Address ; 1030 S OLIVE ST, STOCKTON CERS iD4 10180695 <br /> I certify under penalty of law that: <br /> 1 . I 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 /> andfor Imprisonment for known violations, (HSC 25191 ) t <br /> Name: Vert ! eh Tills: (—'�) Vtko M �ftfi �r <br /> Slgn t#G e: pate <br /> 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468m3420 I F 209 464-0138 I www.sjcehd.eom <br />