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S A N J Q A n U I N Environmental Health Department <br /> C: (DU N I-1Y , - - <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 ( IR) 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 records/other appropriate paperwork , and/or photos verifying corrections <br /> Operator's certification r <br /> Inspection Date : 1 — � � 2 Inspected By : ��, ,�.� ! k- C..) 0 <br /> Facility Address : �� / �� [_� f%o l inQr— /� � CERS ID : �- <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 VIOLATION and <br /> 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. 1 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 : Title : <br /> Signature : Date : <br /> 1868 E . Hazelton Avenue I Stockton , California 95205 I T 209 468-3420 F 209 464-0138 1 www. sjcehd . com <br />