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:> Environmental Health Department <br /> S A N J O A Q U I N AMENDED <br /> •�_'1`5_-- (..I I'CI)(1'1:'tS 111 CI 'i} C'rf, <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 <br /> Inspection Report. HSC 25185(c)(3) <br /> Note: All EHD staff time associated with failing comply IY bY the above noted dates w <br /> p <br /> billed at the current hourly rate. <br /> For this certification to be complete, the operator of the Site must Include: ct <br /> A statement documenting what corrective actions were taken or will be taken for e n �Q <br /> Copies of sample results/manifests/training records/other appropriate paperwork,an r photos verit�ying lG <br /> corrections <br /> Operator's certification ''��J`PQ <br /> Inspection Date: August 29, 2018 Inspected By: Zt A BARKER <br /> Facility Address: 1137 W LATHROP RD, MANTECA CERS ID: 10187387 <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 <br /> and i believe the information to be true,accurate,and complete: <br /> Photos Paperwork—Z—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 /> Name: Title: ti;T S <br /> Signature: l`'1,` !r a-.�G� _-,,v\'.-�------ Date: <br /> .v <br /> 1868 E. Hazelton Avenue I Stockton,California 95205 1 T 209 468-3420 I F 209 464-0138 1 www.sjcehd,com <br />