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San Joaquin County <br /> Environmental Health Department <br /> 1868 East Hazelton Avenue , Stockton , California 95205-6232 <br /> Telephone : (209) 468 - 3420 Fax: (209 ) 468 -3433 Web : www . siaov. org/ehd <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 top 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 violations , <br /> are to be submitted using this certification and returned to EHD within 30 days unless otherwise specified in the Inspection Report . <br /> HSC 25185 (c) (3) <br /> All EHD staff time associated with failing to comply by the above noted dates will be billed at the <br /> 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 : June 16 , 2021 Inspected By : Claudia Muro <br /> Facility Address : 11191 S VALLEJO CT CERS ID : 10183325 <br /> ander penalty of law that: <br /> I have corrected the violations specified in the Inspection Report from the above- mentioned inspection date . <br /> I have personally examined the following documentation submitted as proof of compliance FOR EACH VIOLATION and I believe <br /> the information to be true , accurate , and complete : <br /> Photos Paperwork Statement <br /> I am authorized to submit this certification on behalf of the Respondent . <br /> I 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 : Title : <br /> Signature : Date : <br />