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San Joaquin County <br /> i <br /> Environmental Health Department <br /> 1868 East Hazelton Avenue, Stockton , California 95205-6232 <br /> Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www. sioov. org/ehd s <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 ` <br /> at the top of this form within 30 days of receipt of the Inspection Report . HSC 25404. 1 . 2(c)( 1 ) <br /> R ( All corrections to other violations noted in the attached Inspection Report (IR) or Continuation Form , or disputes to any PRODUd <br /> Tviolations, 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 /> D ( Note : All EHD staff time associated with failing to comply by the above noted dates will be ! <br /> H ; billed at the current hourly rate . <br /> i <br /> Sf 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 /> PC Copies of sample results/manifests/training records/other appropriate paperwork, and/or photos verifying <br /> corrections ; <br /> Operator's certification <br /> Inspection Date : May 18 , 2021 Inspected By : Bohn Alaniz <br /> i <br /> Facility Address : 1612 W HAMMER LN CERS ID : 10181241 !, <br /> I certify under penalty of law that: <br /> 1 . 1 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 /> UPhotos Paperwork Statement , ' ! <br /> 3. 1 am authorized to submit this certification on behalf 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 imprisonment for known violations . ( HSC 25191 ) <br /> Name : .J l Title : f' eLwvVP <br /> Signature: Date : — S Z <br />