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J <br /> SAN !O A Q U I N Environmental Health Department <br /> COUNTY — <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(I R)or Continuation 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 <br /> billed 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 -ecords/other appropriate paperwork, and/or photos verifying corrections <br /> Operator's certification <br /> Inspection Date: January 26, 2022 Inspected By: NICHOLAS LOEHRER <br /> Facility Address: 120 FRANK WEST CIR, STOCKTON CERS ID: 10184157 <br /> I certify under penalty of law that: <br /> 1. I 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 VIOI ATION <br /> and I believe the information to be true, accurate, and complete: <br /> Photos Paperwork _Statement <br /> 3. 1 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 fine and/or <br /> imprisonment for known violations- (HSC 25191) <br /> Name: 4<4- 1tn tm4u Title: C krCl <br /> Signature: 01�/�— Date: <br /> FEB 17 2022 <br /> =NVIRONMENTAL HEALTH <br /> PERMITrSERVICES <br />