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SAN JOA QUIN Environmental Health Department <br /> C (jurvT Y <br /> RF URLM TO CORAM Q " GICLP CL,; G3Rl QG= QG „ u Q o G\1 <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 ) <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 : January 29 , 2020 Inspected By : SHEWIT WOLDEAREGAY <br /> Facility Address : 2072 W YOSEMITE AVE , MANTECA CERS We 10181669 <br /> I certify under penalty of law that: <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 1 , '` Statement <br /> 3 . I 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 :.` ', r. �L 1'� � n � Title :_ <br /> t <br /> Signature : 'Z� i �,- �_ - y Date : <br /> I <br />