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Sj14'It O EnvlronlmlentAQUIN ; il Health Department <br /> P. 111 11 <br /> -- CCbt � l� TY _ <br /> RETURN TO COMPLIANCE CERTIFICATION <br /> Any MINOR violations noted in the " Notice to Comply" In the attached Inspection Report must be = pcted within 34 d s 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 otber viQations noted In the attached Inspection Report (IR) or Continuation Form , or disputes to any <br /> violations, are to be submitted using this certification and retumed to PHD within $, ave unless otherwise specified In the <br /> Inspection Report, HSC 25185(c)(3) <br /> Note : All IwHD 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 records/other appropriate paperwork, and/or phok,os verifying corrections <br /> Operator's certifiostion <br /> Inspection Date ; June 14, 2022 Inspected By : CAROL PRESTO <br /> Facility Address : 1210 E HAMMER LN , STOCKTON CERS ID : 10181355 <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 /> Photos Paperwork L/ Statement <br /> 3. I 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 tho possibility of a fine <br /> and/or imprisonment for known violations. (HSC 25191 ) <br /> Name : All <br /> oe 5 ! \ 1 �.1 c� .. ... Title: _ <br /> _ <br /> Signature : Date : <br /> Sze, y2 �1 <br /> Received Time Jun , 29 , 2022 3 : 03PM No , 1250 <br />