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Aix t .`, �� g Environmental Health Department <br /> SARJOAQUIN <br /> r . <br /> +.Y W+ t � ✓ a ..,... COU1~iT i <br /> mow ` 43 1i41 � i - tl ilf <br /> .� T.•y, ,v4� 1�h, dam{ ` y h 1y fpy 1 <br /> Nn <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 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 (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) j <br /> I <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 /> Inspection Date : August 06, 2019 Inspected By : NICHOLAS LOEHRER <br /> Facility Address : 1260 PHOENIX DR ; MANTECA CERS ID : 10184769 <br /> I 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 <br /> and I believe the information to be true, acc te, and. comple e : <br /> Photos Paperwork . /statement <br /> 3. 1 am authorized to submit this certification on behalf of the Respondent. <br /> 4. I am aware that there are significant penalties for .submitting false information, including the possibility of a fine <br /> and/or imprisonment for <br /> known violations. (HSG 25191 ) <br /> Name : 1 Z. - KV 1 v�n3 Title : Iw c. <br /> Signa ure : Date: - 11 `t CAi <br /> 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 4681AA3420 F 209 464-0138 1 www.sjcehd.com <br />