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SAN JOAQUIN <br /> Environmental Health Department <br /> RETURN TO COMPLIANCE CERTIFICATION <br /> Any MINOR violations noted In th a'NolIce to Comply{In the attached Inspeciion Report must be tvrrectrd within 36 dDVS of <br /> receipt of this Inspection- This certification form mst be submitted to the Environmealal Health Departmont(EHD) address at <br /> the bottom of this farm wilhin 30 days of receipt of the InspeClion Report, HSC 2,6404,1,2(c){1) <br /> All corrections to 01her violations noted io 1he attachud inspection Report(IR)of Continuation Forum,or dispules to any <br /> violations, are to bo wbmilted using this certification and returned to EH within 30 clays unless oiherwise specified in the <br /> I m;pecti an Report. HSC261El5(c)(3) — <br /> Note: All EHD staff time associated with failing to corrlply 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 sila must include: <br /> A slatement documenting what corrective actions were taken or will be taken for etch violation <br /> Copes of sample resultslrrranifestsftrainIng recordsfother appropriale paperwork, andlor photos verifying corrections <br /> Operator's certification <br /> Inspection Date: November 20, 2024 Inspected By: LYE} EY SAMMONS <br /> Facility Address: 2225 Monte Diablo Aire, Stockton CEIRS IQ: 110964500 <br /> 1 riqrtify kinder penalty of law chat- <br /> I I havas mi-raacled the+notations spedfled in the Inspertion Report from the above-rnentloned inspection <br /> date- <br /> .. 1 have personally examined the following docxrrnenlalion submitted as proof of wrnpllance FOR EACH VIOLATION <br /> and I balisve the inrarmalion to be true, sccurale,and romplete: <br /> Pholos Paperwork sialemenl <br /> 3. 1 am authorized to submit Ibis certification on behWf of the Respoa rler)l, <br /> +4- l am aware Mat there are significant penalties for submitting filse infermalion, including the possibility of a fine ancvor <br /> imprisonment for known violations- (HSC 25191) <br /> Marne: 6-VI � ' ` Title: s 'C - b8 &V11A�� <br /> Signature; Date-- i <br />