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- SAN JOAQUIN Environmental Health Department <br /> .. � CUUM11TY.. <br /> � .jl <br /> RETURN 7'p COMPLIANCE CERTIFICATION MI��F �;olations noted in the "Notice to Comply" in the attached Inspection Report must be r�r[ected within 30 days of <br /> receip# of this inspectivr�. This certification farm 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 (1R ) or Continuation Form, or disputes to anyviolafrons , are to be sugmitted 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 AHD 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 /> Inspection Date: December 12., Z024 inspected By:- MARIA LOPEZ <br /> Facility Address : 3714 E , HAMMER LN , STOCKTON CERS ID: <br /> 10182125 <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. I have personally examined the following documentation submitted as proof of compliance FOR EACH VIOLATION <br /> and 1 believe the information to be true, accurate, and complete: <br /> Photos Paperwork Statement <br /> 3. I am authorized to submit this certification an behalf of the Respondent. <br /> 4 . ! am aware that there are significant penalties for submitting false information, including the possibility of a dna andlor <br /> imprisonment for known violations. (HSC 251 97 ) <br />� Name : & 5�w � cmc, <br />� mmmqpnh�Title: ILL MOM <br /> Signature : Date: so � <br />