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San Joaquin County <br /> Environmental Health Department <br /> 1568 East Hazelton Avenue,Stockton,California 95205.6232 <br /> Telephone:(209)468-3420 Fax:(209)468-3433 Web:w�rw.slgov.org/ehd <br /> RETURN TO COMPLIANCE CERTIFICATION <br /> AnyIIUt NOR violations noted in the*Notice to Comply"in the attached Inspection Report must be corrected within_30 da-Y 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 /> All corrections to other violations noted 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 dans unless otherwise specified in the <br /> Inspection Report HSC 25155(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/manifests1t wining recordslother appropriate paperwork,and/or photos verifying <br /> corrections <br /> Operator's certification <br /> Inspection Date: July 12,2022 Inspected By: Paul Nso <br /> Facility Address: 405 S VASCONCELLOS AVE CERS ID: 10183443 <br /> 1 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_X_Staternent <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:`D*wQg MOM-S. Title: C)f'tseAfioms M%,b:tC <br /> Signature: _ �_ _ Date: l 7.2 <br />