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t SANr� OAQUIN Environmental Health Department <br /> --- • CUNTY — <br /> L ` � ©Greatness grows here. <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 at <br /> the bottom of this form within 30 days of receipt of the Inspection Report . HSC 25404. 1 . 2(c)( 1 ) <br /> All corrections to other viol^tions 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 resultstmanifests✓training recordslother appropriate paperwork, and/or photos verifying corrections <br /> Operator's certification <br /> Inspection Date : September 30 , 2020 Inspected By : ELENA MAN7_O <br /> Facility Address: 5475 S VAN ALLEN RD , STOCKTON CERS ID : 1018 / 781 <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 /> yPhotos Paperwork Statement <br /> 3. 1 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 ands <br /> imprisonment for known violations. ( HSC 25191) <br /> Name: Title : <br /> Signature : Date : <br />