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Environmental Wealth Department <br /> 11 4 41 ,I P k SAN SJOANIN <br /> RETURN TO COMPLIANCE CERTIFICATION <br /> Any MINOR violations noted in the "Notioe to Comply" in the attached Inspection Report must be corrected within 3Q dayp 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 viVations, 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 whin 30 days unless otherwise specified in the <br /> Inspection Report. HSC 25185(c)(3) <br /> Nate: All EHD staff time associated with failing to comply by the above noted dates will be billed <br /> 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 16 , 2020 Inspected By: LYDIA BAKER <br /> Facility Address: 4469 S ESCALON BELLOTA RD , FARMINGTO CERS ID : 10187403 <br /> I certify lander penalty of law that: <br /> 1 . I have corrected the violations specified in the Inspection Report from the above-mentioned inspection date. <br /> 2 , I 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 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 irmp6sonment for known violations. (HSC 25191 ) yid <br /> Name: VU 1, DCC -P Title <br /> r jaSignature: _ Date: <br /> Z00fZ00 ' d LZVb # A 3138I3 89Z9988803 28 : 81 0Z0Vl? Z / I, 0 <br />