Laserfiche WebLink
06/11/2021 1:22 PM FAX 2099488625 AMCE SAW [ ] 0001/0005 <br /> RECEIVED BY SJC EHD (EF) ON 6/11/2021 <br /> SAN - JOAQUIN EnvironrftnW Health <br /> RETURN TO COMPLIANCE CERTIFICATION <br /> Any MINOR violations noted in the"Notice to comply,,in the attached Inspection Report must be eQugted within 30 days of <br /> receipt of this inspection, This certification form must be submitted to the F nvironmental 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 EHD within 30 da s 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, 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/othor appropriate paperwork, and/or photos verifying corrections <br /> Operator's certification <br /> Inspection Date: May 12, 2021 Inspected By: ELIANNA FLORIDO <br /> Facility Address: 1204 E MAIN ST, STOCKTON CERS ID: 10/51671 <br /> rcortify der penalty of law that; <br /> 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 �" 7p'aperwork— Statement <br /> 3, 1 am authorized to submit this certification on bohalf of the Respondent. <br /> 4. 1 am aware that there are significant penalties for submitting false information, including the possibility of a fine <br /> and/or impris r <br /> ent for known violations. (NSC 25191) <br /> Name: <br /> Signature: _Date: <br /> RECENED <br /> JUN 1 1 2021 <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br />