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± JEnvironmental Health Department <br /> COUNTY- <br /> RETURN <br /> NTY- <br /> RETU N TO COMPLIANCE CERTIFICATION <br /> 1- <br /> Any U I NOR violations noted in the 'Notice to Comply" In the attached Inspection Report must be corrected within 30 days of <br /> receGpt of this inspection. This celVica#ion form must be submitted to the Environmental Health Department(EHD) address at <br /> the bottom of this form within 30 dogs of receipt of the Inspection Report, HSC 25404A.2(c)(1) <br /> All corrections tQ othQr y1olattons noted in the attached Inspection Report (IR)or Continuaklon Form, or disputes to any <br /> violations, are to be submitted using this cartification and returned to EHD within 30 dao unless otherwise specified in the ' <br /> inspection Report. HSC 25185(c)(3) <br /> Note: All EH staff time associated with failing to comply by the above noted Mates will. be <br /> billed at the current hourly rate. <br /> For this oertlflcat ion to be compI ete, the operator of the site must includrv: <br /> A statement do(,,vm trrrg what corrective actrorrs Yr'ere taken or oa&be bken dor'asch vn b on <br /> Copies of sample'resuitsti-nanifests!#raining recordslokhEr appropriate paperwork, andfarphotos verifying corrections <br /> Operator's certification <br /> Inspection Date: September 17, 2020 Inspected By: ROBERT LOPE <br /> Facility Address: 2855 MUN FORD AVE, STOCKTON DERS ID: 10142157 <br /> certify under penalty of law that; <br /> 1, +have corrected the Wditions spec+Fred 0 the ir'rspecfaarr ReW from the&bcs, -nlerrliorrsd hspadoa dste. <br /> 2. 1 have personally examined the fotlovaing documentation submitted as proof of compliance FOR EACH VIOLATION <br /> and I believe the information to be true, aocura#e, and complete: <br /> Photos Paperwork v #aternent <br /> 3. 1 am authorized to submit this certifiication on behalf of the Respondent. <br /> 4. 1 am aware that there aro significant penalties for submitting False information, including the possibility of a fine andl< <br /> imprisonment For known violations, (HSC 25191) <br /> Name. Tii<le- . <br /> ignatur Date, <br />