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SAN JOAQUIN Environmental Health Department <br /> I ell ? <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 ai <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 : October 16 , 2019 Inspected By : CHRISTINE LAWRENCE <br /> Facility Address : 180 BUTTON AVE , MANTECA CERS ID : 10646032 <br /> 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 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 and/ <br /> imprisonment for known violations . ( HSC 25191) <br /> Name : sh Title : <br /> Signature : Date : <br /> 7V <br /> RECEIVED <br /> JAN 16 2020 <br /> ENVIRONMENTAL HEALTH <br /> PERMIT/ SERVICES <br />