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SAN�jOAQU IN <br />�teatne.ss gTovrs here. <br />6L99'°N Wd05�6 IZOZ 'Z 'ady au�il panic°a� <br />Environmental Health Department <br />RETURN TO COIVIPLIANCE CERTIFICATION <br />Any Ij�l NOR violations noted in the."Notice to Comply" in th® attached Inspection Report must be corrected withln 30 days of <br />receipt of this inspection. This certification form must be submitted to tha Environmental Health Department (EHD) address et <br />the bottom of this form within 30 days of receipt of the Inspection Report. HSC 25404.1-2(c)(1) <br />All co ctions to th®r violatlo noted in the attached Inspection Report•(IR) or ContlnuaGon Form, or disputes to any <br />violations, are to be submitted using this certification and returned to EHD withln 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 th® 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 wore taken or will be taken for oach violation <br />Copies of sample results/manifests/training recordsJother appropriate paperwork, and/or photos verifying corrections <br />- Operator's certification <br />Inspection Date: August 05, 2020 Inspected By: CLAUDIA MURO <br />Facility Address: 6129 N WEST LN, STOCKTON CERS ID: <br />I certify under penalty of law that: <br />10184255 <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 PaperworK Statement <br />3- I am authorized to submit this certification on behalf of the Respondent. <br />4. I am aware that (here are significant penalties for submitting false Information, including the possibility of a fine and/or <br />imprisonment fnr known violations-• (MSC 25191) <br />Signal <br />�' �2 - 2"t <br />Ai'R 0 2 2021 <br />ENVIRONMENTAL HEALTH <br />PERMIT/SERVICES <br />LO/b0 3J'dd 3Nf11�3�b'�93Nd�1S3i1h h8988Lb60Z 4'!b'99 �80 �ZOZ/ZO/b0 <br />