Laserfiche WebLink
0■� 26 2017 03:14PM Manteca Midas 2098250440 <br />■ <br />■ <br />M% <br />SAKJOAQUIN <br />v <br />0 U i,4 'f Y <br />page 1 <br />Environmental Health Department <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 <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 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 <br />corrections <br />Operator's certification <br />Inspection Date: November 16, 2017 <br />Facility Address: 1412 W YOSEMITE AVE, MANTECA <br />I certify under penalty of law that: <br />Inspected By: NICHOLAS LOEHRER <br />CERS ID: 10183369 <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 <br />and I 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 <br />and/or imprisonment for known violations. (HSC 25191) <br />j � r <br />Name: I� t'1 IJ Title: 4� 51 cltc� <br />Signature: K`z Date: � —IK- Z- 0 t <br />RECEIVED <br />NOV 2 7 2017 <br />ENVIRONMENTAL HEALTH <br />PERMIT/SERVICES <br />1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-34201 F 209 464-0138 1 www sicehd-com <br />Received Time Nov.26, 2017 2:23PM No -2622 <br />