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r <br /> AN J OA Q U I N Environmental Health Department <br /> —_ ( U U N l Y-._.._. <br /> Grr; ;s grows herr, <br /> ' <br /> RETURN� TO COMPLIANCE CERT IFICATION <br /> Q � <br /> +� yNNOR violations noted in the"Notice to Comply"in the attached Inspection Report must be corrected within 30 da s of <br /> d rreceipt of this inspection. This certification form must be submitted to the Environmental <br /> the bottom of this form within 30 days of receipt of the Inspection Report. 1. Health Department(EHD)address at .t <br /> p HSC 25404.1.2(c)(1) <br /> All corrections to other violations noted in the attached Inspection Report(IR)or Continuation Form or disputes +/ <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) it <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 <br /> I August31, 2020 <br /> Inspection Date: / <br /> � <br /> Inspected By: STACY RIVERA <br /> Facility Address: 437 N WILSON WAY, STOCKTON <br /> I certify under penalty of law that: CERS ID: 10180899 <br /> 1• I have corrected the violations specified in the Inspection Report from the above-mention ' <br /> 2• 1 have personally examined the following documentation submitted as proof of compliance FOR inspection date. <br /> and I believe the information to be true, accurate, and complete: <br /> yp„ REACH VIOLATION <br /> _ Photos__paperwork0 00 <br />` 3• I am authorized to submit this certification on b Statement a„ <br /> behalf of the Respondent. <br /> 4• I am aware that there are significant penalties for submitting false information i � .ems <br /> imprisonment for known violations. (HSC 25191) <br /> including <br /> the possibility of a fine and/or <br /> Name: <br /> Title: <br /> Date: <br />