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Feb . 09 . 2021 01 : 11 PM Ernie ' s General Store & D 2099312871 PAGE . 3 / 3 <br /> Q Q u N Environmental Health Department <br /> SAN , JD ; i � . <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 2640411 . 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 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 results/manifests/training records/other appropriate paperwork, and/or photos verifying corrections <br /> Operator' s certification <br /> Inspection Date : January 28 , 2021 Inspected By : STACY RIVERA <br /> Facility Address : 4407 E WATERLOO RD , STOCKTON CERS ID : 10180913 <br /> I certify under penalty of law that: <br /> 1 . 1 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 and/ or <br /> imprisonment for known violations . (HSC 25191 ) <br /> Name ; e l �� � C-" !' Title . �►^ e � <br /> Signature . Date , -� Ap Ilea- I <br /> t <br /> RECEIVED <br /> FEB 0 9 2021 <br /> ENVIRONMENTAL HEALTH <br /> PERMIT/ SERVICES <br /> Received Time Feb , 9 . 2021 11134AM No , 6593 <br />