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SAN J O A Q U I N Environmental Health Department <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 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 END 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 corrections <br /> Operator ' s certification <br /> Inspection Date : November 02 , 2020 Inspected By : ELIANNA FLORIDO <br /> Facility Address : 4950 PACIFIC AVE STE 425 , STOCKTON CERS ID : 10737790 <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 . I 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 ti ' Paperwork "' Statement <br /> 3 . I 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 and / or <br /> imprisonment for known violations . ( HSC 25191 ) fJ <br /> Name : liGt )Q. � �l ZI Title : I�Ct.�ful4 �' � � � �• ka �j,{i( � � �' � <br /> Signature : ' Date : Z l Z <br />