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AQUEnvironmental Health Department <br />SAN COUNTY, ..... <br />RETURN. T4 COMPLIANCE CERTIFICATION <br />Any ILIILlOR violations noted in the "Notice to Comply' iri the:CA ko ed Inspection Report must be corrected.within 30 days of <br />receipt ofthisinspection. This certification form must be submitted to the Environmental Health Department (EHD) address r <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:attaclied 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 />Nate: All EHD.staff time associated wi#h failing to comply ay the above Hated dates will be <br />billed at the current hourly rate. <br />For this certificafiiorl 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/mahifests/training records/other appropriate paperwork, acid/or photos verifying corrections <br />Operator's- certification <br />Inspection Date: May 20; 2019 Inspected By: STACY RIVERA <br />Facility Address:. 1532 N Broadway Ave, Stockton CERS ID: 1.0156057 <br />1 certify under penalty of lawthat, <br />1.. 1 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 <br />EACH VIOLATION <br />I believe the information to be true; accurate, and complete: <br />Photos _,,.•,.,Paperwork � Statement <br />3. I am. author"zed to submit this certifi <br />cation on behalf of the Respondent. <br />4. I _am aware that there are significant penalties for submitting false informati <br />on,. including the possibility of a tine <br />imprisonment for known violations. {HSC 25191) <br />�I <br />Signatu <br />'1868 E. Hazelton Avenue � Stockton; California 95205 � T 209 468,3420 j F 209 464-013& (www.sjcetid.coni <br />