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Environmental:Health DePartrnent <br /> RETURN TO COMPLIANCE CERTIFICATION <br /> Any UVO violations noted in the"Notice to COMOY"in the attached Inspection Report must be pDrrecte.9-.within_LOA19)0:Of <br /> ss a <br /> receipt Of this inspection. This certification form MUSt be Submitted I:o the Environmental Health Department(EHD)addre <br /> the bottom of this form within 30 days or receipt of the Inspection ROPOrt, HSC;26404-1.2(c)(1) <br /> All correctio to other�WzLtions. noted in the attached Inspection Report(IR)or Continuation Form,or disputes io Iny <br /> cl in the <br /> violations,are to be submitted using this certification and returned to EHD w <br /> �,_thin 39_Lasunless otherwise speCift <br /> Inspection Report, HSC 2$185(c)(3) <br /> Note; All EHD staff time associates! with failing to comply by the above noted dates 'Will b8 <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 /> roplea of sample results/manifests/training recordslother appropriate paperwork,andlor photos verifying corrections <br /> Operator's certification <br /> Inspection Date' .January 20, 2022 Inspected By: FREDERICK ERNEST <br /> _OY ST, STOCKTON CERS W' 10187413 <br /> acuity Address: 818 MCCI. <br /> r I certify Linder penalty of law that <br /> have corrected the violations specified in the inspection Report from the above-mentioned inspection d-EA0. <br /> 77 the following documentation submitted as proof of compliance FOR EACH VIOLATION <br /> 2. 1 have personally examined lete; <br /> and I believe the information to be true, accural.e.,and comp <br /> Photos Paperwork Statement <br /> 3, 1 am authorized to submit this certification on bk�half of the Respondent. <br /> 4. 1 am aware that there are significant penalties for submining false information,including the possibility Of R fine <br /> and/or imprisonment for known violations. (HSC 25191) <br /> title: <br /> Name. _71\7n,1A <br /> D <br /> Signature: <br />