Laserfiche WebLink
i <br /> SAN 1 U A Q U I N 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 : January 28 , 2019 Inspected By : LYDIA BAKER <br /> Facility Address : 1029 W Yosemite Ave , Manteca CERS ID : 10669177 <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 , accurate , and complete : <br /> _Photos XPaperwork _XStatement <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 /> Name : _1 � .Aa IQ l 1Gf i Ch, Title :.0 <br /> Signature : <br /> Date : `�� <br /> JAN 3 It 2019 <br /> ENVIRONMENTAL HENT ) <br /> ) <br /> PER NPSERVIL � s <br /> 1868 E . Hazelton Avenue I Stockton , California 95205 T 209 468-3420 F 209 464 -0138 1 vAvw.sjcelid . com <br />