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SAJQbVUIN Environmental Health Department <br /> _, j.. COUNTY <br /> RETURN TO COMPLIANCE CERTIFICATION <br /> Any MINOR violations noted in the'Notice to Comply'in the attached Inspection Reportmust 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 the <br /> bottom of this form within 30 days of receipt of the Inspection Report. HSC 25404.1.2(cx1) <br /> All corrections to other violations noted in the attached Inspection Report(IR)or Continuation Form,or disputes to any violations, <br /> are to be submitted using this certification and returned to EHD within 30 days unless otherwise specified in the Inspection <br /> Report. HSC 25185(cx3) <br /> Note: All EHD staff time associated with failing to comply by the above noted dates will be billed <br /> at the current hourly rate. <br /> Forthis 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 recordsrother appropriate paperwork,and/or photos verifying corrections <br /> Operator's certification <br /> Inspection Date: October 01, 2019 Inspected By: CESAR RUVALCABA <br /> Facility Address: 800 MELLON AVE, MANTECA CERS ID: 10181315 <br /> 1 certify under penalty of law that: <br /> 1. 1 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 /> 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 and/or <br /> imprisonment for known violations. (HSC 25191) <br /> Name: Title: <br /> Signature:__ ———————Date <br /> 1868 E.Hazelton Avenue I Stockton,California 95205 1 T 209468-3420 1 F 209464-0138 1 www.sjcehd.com <br />