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� � . �r ��. Environmental Health Dmend <br /> SAN .,,-- J0A0U. IN <br /> P. , i b;. C 0 U N T Y%m— <br /> F. <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 da sof <br /> receipt of this inspection . This certification form must be submitted to the Environmental Health Department (EHE) 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 Hated 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 d_a_ys 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 <br /> Willed at the current hourly rate. <br /> For th 'i s certification to be co m p I ete , 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 : September 24 , 2021 Inspected By : NICHOLAS LOEHRER <br /> Facility Address : 1789 111J CHARTER WAY , STOCKTON CERS 1D : 10182247 <br /> certify under penally of law that : <br /> 1 . I have corrected the violations specified in the Inspection Report from the above-mentioned inspection date. <br /> 2 . { have personally examined the following documentation submitted as proof of compliance FOR EACH VIOLATION <br /> and i believe the informs#ion to be true, accurate , and complete: <br /> t <br /> Photos -Paperwork Statement <br /> 3 . [ am authorized to submit this certification on behalf of the Respondent. <br /> 4. i am aware that there are significant penalties for submitting false information , including the possibility of a fire and/or <br /> imprisonment for known violations . (HSC 251 91 ) <br /> w <br /> Name: Title: � f� , Vt�,k I.�r. <br /> Signature . Date : <br />