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SAN JUAQUIN <br />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 Continuallon 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 billed <br />at the current hourly rate. <br />For this certification to be complete, tl�e 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: April 07, 2021 Inspected By: PAUL NSO <br />Facility Address: X100 E FREMONT ST, STOCKTON <br />I certify under penalty of law that: <br />1. I have corrected the <br />CERS ID: 10180875 <br />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 <br />/ \ Statement <br />3. I am authorized to submit this certifi <br />cation an behalf of the Respondent. <br />4. I am aware that there are significant penalties for submitting false information, including the possibility of a fine <br />and/or impr' onment r known violalions.�SC 25191) <br />Name; ►''�1 irk ,iV C� Title, ,_)Wr e <br />Signatu <br />Date: <br />